The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

24
I Fundamentals
with wedding photography using available light, or astronomical
photographs that capture thousands of stars too faint to see with
the naked eye.
As previously mentioned, lenses have worse image quality at
the extremes of their performance³at the widest and smallest
apertures, images will be less crisp. As a rule of thumb, most
lenses have a ´sweet spotµ for maximum image sharpness in
the midrange. For clinical photographs, an aperture in this middle
range around f/7 to f/11 will provide crisp images while providing a
EURDG GHSWK Rf fiHOG WKDW HQVXUHV RWKHU GHWDLOV LQ WKH LPDJH UHPDLQ LQ
focus as well. Depth of field is a more complex but very important
topic, discussed in a later section.
Sensitivity (ISO Speed)
Films differ in their sensitivity to light, and so do digital sensors. A
high-sensitivity film or sensor requires less light (fewer photons)
to activate an individual point (pixel) in the image; a lower-sensi-
tivity film or sensor requires more light (more photons) to get the
same activation. For the camera to collect more photons, either
there has to be more available light to begin with (e.g., bright sun-
light rather than shade), or the aperture has to be wider (lower
f-stop), or the exposure has to be longer (slower shutter speed). At
a given light level and f-stop, a more sensitive film or sensor takes
less time to collect enough light to activate it, so it is said to be
´fast,µ just as a wider lens that allows a low f-stop is.
The International Organization for Standardization (ISO) has
determined an industry scale for the ´speedµ or sensitivity of a
film or sensor to light, replacing older different scales used in
the United States and Europe. Today the speed rating of a film or
sensor is often called simply its ´ISO.µ High ISO represents high
sensitivity, so fewer photons are required to activate the sensor,
and conversely low ISO means low sensitivity and requires more
photons. A sensor with ISO 100 requires twice as much light as a
sensor with ISO 200.
High-ISO films and sensors allow shooting in darker places, use
of higher f-stops (giving better focus, as will be discussed later),
and faster shutter speeds (for sharper views of moving subjects),
but they tend to produce images that are grainy and noisy. If only
three or four photons are necessary to activate a given individual
point element (pixel) of the sensor, then one stray photon has a
greater chance of erroneously activating the pixel. On the other
hand, a low-ISO sensor might require a thousand photons for
activating a pixel, so it will not be affected by one stray photon.
Images taken with a low ISO are smoother, less noisy, and less
grainy, and ultimately higher-quality and more useful.
Because lower-ISO images produce less grainy images, optimal
photographs use the lowest possible ISO that still allows an accept-
able shutter speed and the desired aperture. Most cameras have
an ´auto ISOµ setting that automatically uses the lowest acceptable
setting while maintaining a usable shutter speed.
3.3.2 Exposure
Conceptually, exposure represents the cumulative light cap-
tured within a photograph, as determined by the shutter speed,
aperture, and film sensitivity (ISO). A common analogy is filling
a bucket with water from a faucet. The exposure represents the
total volume of water (volume of photons) collected. The amount
of opening of the faucet valve represents the aperture setting of
the lens, and the amount of time that the faucet runs represents
the shutter speed. Thus, the volume of water is determined by
the opening of the valve and the amount of time the faucet is
open. This is equivalent to the cross-sectional area multiplied
by the time, which parallels the lens aperture multiplied by the
shutter speed.
Continuing this analogy, the sensor ISO then represents the
size of the water bucket. For proper exposure, the bucket requires
filling exactly to the brim. If the bucket is underfilled, the sensor is
not activated, and the photograph is underexposed and too dark.
Overfilling the bucket causes too much light to reach the sensor,
and the photograph becomes overexposed and too bright.
A small bucket represents a high-ISO, highly sensitive sensor,
which requires only very little water/light to be properly exposed.
A large bucket represents a low-ISO/low sensitivity sensor that
requires much more water/light.
There is a tradeoff between shutter speed and aperture, as
demonstrated in Fig. 3.4. Both frames have equivalent exposure,
or the total amount of light collected, so the dog, the grass, the
sea, and the sky have the same colors and brightnesses in both.
Fig. 3.4 Tradeoff between aperture and shutter speed, with constant
ISO. Both frames have equivalent cumulative exposure but differing
depth of field and motion blur. (a) 1/320 sec, f/8.0, ISO 100 creates a
wide depth of field and a detailed background, at the cost of motion
blur. (b) 1/8,000 sec, f/1.8, ISO 100 eliminates motion blur but has a
shallow depth of field with a blurred background.
a
b

3 Photographic Essentials in Aesthetic Surgery
25
Fig. 3.4a uses a small aperture of f/8.0, which requires a shutter of
1/320 sec for proper exposure at this light level and ISO speed. The
depth of field (discussed in the next section) is broad, meaning
that detail in the farthest parts of the landscape is as sharply
focused as the foreground. However, the dog’s motion makes him
look blurry at this shutter speed. Fig. 3.4b uses a large aperture of
f/1.8, which requires only 1/8,000 sec shutter for equivalent expo-
sure. The dog appears sharp despite his motion, but the depth of
field is shallow, with everything farther than the dog blurred. The
difference in the photographs is significant despite the point of
focus being the dog in both photos.
SLR cameras and some point-and-shoot cameras allow the
photographer to force the camera to maintain a certain aper-
ture (´aperture priorityµ) or shutter (´shutter priorityµ) while
automatically computing the other variables to maintain proper
exposure. ´Programµ mode allows the user to determine the
aperture and shutter, while automatically calculating ISO. Manual
mode allows the user to set shutter, aperture, and ISO, and is the
best for the user to learn the concept of exposure.
3.4 Advanced Concepts
3.4.1 Depth of Field
The GHSWK Rf fiHOG describes the zone in front of and behind the
focal plane where objects appear to be in focus and are acceptably
sharp (Fig. 3.5). Depth of field is determined by a combination of
aperture size, subject distance, focal length, and sensor size, but
it is most easily controlled by varying the aperture.
A conceptual understanding of depth of field helps the photog-
rapher to use it meaningfully. Objects closer than the focal plane
are focused by the lens at a spot behind the sensor, so they appear
as a blurry spot on the sensor. Objects farther than the focal plane
come into focus in front of the sensor and subsequently defocus,
so they appear as blur spots as well.
:ith all camera settings equal, the size of the blur spots varies
depending on an object’s distance from the focal plane. There is a
distance in front of and behind the focal plane where the resulting
blur spots are small enough that they appear to be in focus. This
range is referred to as depth of field (Fig. 3.6).
Decreasing the aperture size will also decrease the size of the
blur spots, thus making the depth of field wider. Clinical pho-
tographs are best taken using a smaller aperture to maintain a
broad depth of field, ensuring that details across all contours of
the patient remain in focus.
In nonclinical portrait photography a narrow depth of field
can be advantageous and aesthetically pleasing, since attention
is inherently drawn toward the only object in focus³the subject.
To truly create the narrowest depth of field possible, a combina-
tion of largest aperture size; shortest subject distance; longest
focal length; and largest sensor size possible would be used. In
practice the camera should be set to the largest aperture available
(the lowest f/number), which in commercially available high-end
lenses is commonly f/1.2.
However, shallow depth of field is not suitable for clinical use
because of the loss of detail out of the focal plane (Fig. 3.7). A
broad depth of field should be utilized in clinical situations,
ensuring that both the nasal tip and the helical rim of the ear
appear focused.
3.4.2 Lighting and Flash
In the clinical setting, lighting conditions are often suboptimal.
Various types of supplemental light sources compensate, includ-
ing on-camera flash, external flash, and remote flash. However,
single point sources of light create harsh shadows and highlight
contours, similar to direct sunlight. 1o matter the type of device,
the underlying goal remains the same: to create a broad source
of noncoherent light that illuminates the subject from multiple
angles. Such ideal sources of light provide ´softµ illumination
without casting harsh shadows.
Classic examples of ideal light include sunlight filtering through
a white curtain (used commonly by wedding photographers),
bright overcast days, or sunlight reflecting from a broad white
wall. Studio photography recreates this effect using multiple
flashes reflecting from umbrellas.
Fig. 3.5 Example of shallow versus wide depth of field. (a) The large aperture of f/2.8 creates a shallow depth of field and consequently loses fine
detail in the medication labels out of the focal plane. (b) The small aperture of f/11 preserves fine detail out of the focal plane and is more useful in
clinical situations.
a
b

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In the clinical setting, it is not often practical to re-create studio
lighting. Ideally, a dedicated photography studio setup would be
created in the clinic, consisting of three light sources as in Fig. 3.8.
The key light provides main illumination, while the fill light illu-
minates areas missed by the key light. The back light illuminates
the back of the subject, enhancing edges and borders.
On the ward, carrying around a three-point lighting setup is
impossible. The most suitable alternatives include an on-camera
or external flash, as discussed later in the chapter. The external
flash may be used as a bounce flash, in which the external flash
is directed upward toward the ceiling or backward toward the
wall behind the camera. The light reflects from the ceiling or wall
and acts a surrogate to a broad diffuse source of light. The built-in
on-camera flash is the simplest, most direct option.
In the operating room, lighting conditions are variable.
However, overhead lights can be used to emulate broad sources of
light (Fig. 3.9). By utilizing multiple overhead lights, it is possible
to simulate diffuse light. In Fig. 3.10, multiple overhead lights are
used to eliminate shadow and simulate a broad source of light:
one light is behind the subject, another in front, and another to
the side. Fig. 3.11 shows an example of a photo taken using mul-
tidirectional overhead operating light. Having said that, operating
room lights can cause white-out and harsh, overexposed photos
or photos with a ´spotlightµ effect (bright and overexposed in
the middle and dark on the borders), so sometimes it is best to
direct the operating room lights away from the field and adjust
the camera settings accordingly.
3.4.3 Metering
:ithin the camera, light meters monitor the intensity of incom-
ing light and calculate the appropriate shutter and aperture for
proper exposure. By selectively limiting the area being sampled,
various metering modes permit more accurate exposure for a
specific region of interest.
Fig. 3.6 Illustration of depth of field. Point A (blue) lies within the
focal plane and correctly focuses as a point on the sensor. Point X
(red) is behind the focal plane; light from this point is focused by the
lens and then diverges and appears out of focus. Point Y (yellow) is in
front of the focal plane, so light from it has not come into focus and
also appears out of focus on the sensor. Point Z (green) is in front of
the focal plane but within the depth of field, and it appears as a small
enough blur spot that it is considered to be in acceptable focus by the
observer.
Fig. 3.7 (a) This photo demonstrates an extremely shallow depth of
field, which is pleasing in portraits but should be avoided in clinical
photos due to loss of detail. (b) Although the eyes are in focus, the
eyebrows, nose, and ears all appear blurry.
a
b

3 Photographic Essentials in Aesthetic Surgery
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The default, evaluative metering, assesses the light levels across
the whole scene in order to determine correct exposure; this is
useful for travel or recreational use (Fig. 3.12a). However, proper
exposure as determined by the camera may be unsatisfactory
to the photographer. This commonly occurs in certain surgical
photos, creating photos that are too dark and lack detail of desired
anatomy. Correction requires proper exposure. Aside from man-
ually changing the shutter, aperture, and ISO, corrections can be
automated by altering the camera’s metering mode and exposure
compensation.
By changing metering to center-weighted (the center of the pho-
tograph is used to calculate exposure, regardless of focus point;
Fig. 3.12b) or spot (exposure based on the focus point; Fig. 3.12c),
the photographer instructs the camera to calculate the correct
exposure based on a smaller, more specific area of interest.
Exposure compensation instructs the camera to overexpose or
underexpose the photo automatically. For instance, in Fig. 3.13a,
the building and person are underexposed and the clouds are
overexposed; detail has been lost in both subjects. To visualize
detail in the underexposed building and person, exposure com-
pensation can be set to overexpose the photograph. This results in
a properly exposed building and face, at the cost of an even more
overexposed cloud (Fig. 3.13c).
In the clinical setting, wounds tend to be composed of darker
tissue (muscle, ecchymoses, and eschar for instance) and may
be located in difficult-to-illuminate areas (decubitus ulcers).
Important details can be revealed by forcing camera overexposure.
With image software postprocessing, photos are more accept-
able when they are overexposed and then darkened, as opposed
to underexposed and then lightened, as the latter results in grainy,
Fig. 3.9 Modern overhead operating room lights in fact behave as
multi-point-source light sources.
Fig. 3.8 Three-point lighting for portrait photography consisting of a
main key light, fill light, and a back light.
Fig. 3.11 Operating room photograph taken using three overhead
operating lights combined into natural-appearing diffuse lighting.
Fig. 3.10 In combination, multiple overhead lights produce even
illumination from multiple directions, eliminating distracting shadow.

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noisy photographs that are less useful. In the hospital setting, it is
often helpful to set exposure compensation to 2/3 or 1 f-stop.
3.4.4 Postprocessing
Despite careful planning, in some instances the ideal exposure
is not always obtained, resulting in unusable photographs.
Fortunately, powerful programs are available to rescue such
photographs through postprocessing, referring to the process
of adjusting an already-captured image to achieve a desired
appearance, without manipulating the content of the photo.
Although powerful image manipulation software is available,
it is crucial not to create misleading appearances or enhance
results. Instead, the goal should be to correct for suboptimal
lighting conditions and/or reproduce lighting conditions to allow
comparison between photos.
The most useful and high-yield basic adjustments include white
balance and exposure correction. Sharpening and vignette correc-
tion can add subtle but significant refinement. For intraoperative
photos it is helpful to darken the highlights, lighten the shadows,
and selectively decrease red saturation to allow details within
bloody surgical wounds to be visible. Local adjustment masks can
be used to correct for suboptimal lighting and reveal detail within
shadows. Combined, postprocessing adjustments can rescue a
poor photograph as in Fig. 3.14.
When selecting postprocessing software, it is recommended to
use programs with nondestructive editing, in which the original
photo remains intact and can be restored. Editing is stored separately
in a separate file or program catalog. Using such software, a series
of adjustments can be stored as a ´shortcutµ for different lighting
situations, for instance ´clinic,µ ´operating room with flash,µ ´oper-
ating room without flash,µ and so on, and photos can be processed
Fig. 3.13 Exposure compensation allows detail to be revealed in regions of interest. (a) Using the default exposure setting, the building and person
are underexposed and the clouds are overexposed. (b) Setting −1 f-stop exposure compensation reveals detail within the clouds. (c) Setting +1 f-stop
makes the building detail visible and gives the person’s face a natural appearance.
a
b
c
Fig. 3.12 Red shading represents the selected region used by a camera to determine the correct exposure. (a) Evaluative metering. (b) Center-
weighted metering. (c) Spot metering.
a
b
c

3 Photographic Essentials in Aesthetic Surgery
29
quickly and efficiently. :hen exporting photos, it is recommended
to remove file metadata so as to remove GPS information, time/date
information, and other identifiable characteristics.
3.4.5 Compressed vs. Uncompressed
vs. Raw Format
Postprocessing provides the best results when working with
uncompressed raw format files, which are the digital equivalent
of film negatives and retain all original data. Photos are com-
pletely uncompressed and retain the most information, so
there is no data loss in shadows or highlights, as with formats
compressed for the sake of file size. :ithout editing, photos
often appear washed out and faded. However, these photos
have the most potential; after processing parameters such
as exposure, white balance, contrast, and other adjustment,
these may produce the most dramatic photos once edited
(Fig. 3.15).
Fig. 3.14 (a) Original photograph taken with suboptimal lighting conditions, resulting in uneven lighting and unnatural color. (b) Postprocessing the
raw format file allows for correction of color, exposure, and uneven lighting distribution.
a
b
Fig. 3.15 Example of postprocessing. (a) The unprocessed raw image of the same scene as in Fig. 3.13, exposed at a level between those of Fig. 3.13a
and Fig. 3.13b, appears dull and washed out. (b) After postprocessing correction, the texture and detail are revealed vividly within both the building
surface and the clouds, a result that could not have been obtained with exposure compensation alone.
a
b

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However, if storage space is a concern, as with email or inter-
net photo sharing, compressed formats may be desirable. All
compressed formats trade convenience of file size in exchange
for loss of information that the user is less likely to notice. At the
time of print, the most common file compressed format used
is the -oint Photographic Experts Group (-PEG). In this format,
information is discarded in less perceptible regions, such as fine
details in the darkest portions of shadows. -PEG files are not ideal
for postprocessing, because information has been discarded and
cannot be rescued, resulting in odd artifacts. This is known as
lossy compression, where information is lost every time the file
is saved. The compression generates artifacts that distort fine
details with increasingly higher compression levels, as shown
in Fig. 3.16.
For the best photo quality and most control over file size, if photo
postprocessing is anticipated, it is optimal to shoot photos in raw
format and subsequently convert to a compressed format such
as -PEG for sharing. If postprocessing is minimal or not desired,
files may conveniently be taken in -PEG format with relatively low
levels of compression.
As will be discussed in more detail subsequently, the advent
of cloud storage and high-speed Internet communications and
decreasing memory and disk space costs make the need for com-
pression less of a concern.
3.5 Considerations in
Digital Photography
3.5.1 &KDrDFWeriVWiFV A̵eFWing
Image Quality
Sensor Size
:ith an identical megapixel resolution, a larger sensor has larger
pixels. Each pixel captures more light, resulting in less noise and a
smoother image. High-end full-frame cameras have sensors equiv-
alent to a 35-mm film frame (36 mm ð 24 mm in size) but conse-
quently require larger, heavier lenses and camera bodies. Many
consumer-level cameras have smaller sensors for convenience,
demonstrated by the Advanced Photo Systems (APS) sensors (14
ð 21 mm to 16 ð 24 mm) and Four Thirds sensors (12 ð 17.3 mm).
Top-of-the-line digital medium format cameras have 48-mm ð
36-mm sensors and currently cost tens of thousands of dollars.
The ratio of a 35-mm sensor diagonal (43.3 mm) to a given cam-
era’s sensor is termed the crop factor. With identical conditions,
lenses, and settings, two differently sized sensors will produce
different photographs, as illustrated in Fig. 3.17. The smaller
sensor samples a smaller area, effectively magnifying the image
Fig. 3.16 Example of artifacts and loss of information detail with high Joint Photographic Experts Group (JPEG) image compression. (a,c) The 1:1
zoom shows fine details within the iris and scleral capillaries. (b,d) With unacceptably high JPEG compression, blocky artifacts distort the image.
a
c
b
d

3 Photographic Essentials in Aesthetic Surgery
31
with the equivalence of a new H̵HFWLYH fRFDO OHQJWK, calculated
by multiplying the original focal length by the crop factor. In a
similar fashion, the aperture and corresponding H̵HFWLYH fVWRS are
calculated by multiplying the f/number by the crop factor as well.
Thus, when using an APS sensor with a 1.6x crop factor, to create
portrait photos with the appearance of an 85-mm portrait lens, a
50-mm lens should be used, since 50 mm ð 1.6 80 mm.
Resolution
Adequate camera sensor resolution for publication is no longer
a significant concern, as newer cameras have far greater resolu-
tion than necessary. :hen decreasing resolution within camera
settings or during storage, it is recommended to store photos
at 7.6 megapixels or greater, which would allow for an
8 ð 10µ photo print at 300 pixels per inch (ppi). Higher-
resolution files, preserving finer detail, are recommended
if practical. Storage practicalities are discussed later in this
section.
Dynamic Range
Dynamic range represents the ability of a sensor to identify
information across varying levels of brightness, determining the
quantity of detailed information captured in the very brightest
and darkest areas of a scene. Outside of this detectable range,
anything brighter appears as ´blown outµ white areas, and
anything darker appears as plain black. The information in
these outer regions is not captured and cannot be rescued with
postprocessing. If the scene’s dynamic range is broader than the
camera’s dynamic range, then information will be lost in the
scene. The comparison between the dynamic range of the human
eye and that of a digital sensor is shown in Fig. 3.18. Because
of the human eye’s superior dynamic range, scenes with highly
varying brightness, such as sunsets, are far more stunning in
person than in photos.
Dynamic range depends on the quality of the sensor and the
file format. High-end camera sensors are able to distinguish light
across a broader range of light intensity. Raw, uncompressed files
Fig. 3.17 (a) Any camera sensor samples only a fraction of the image projected by the lens, cropping the original image. The yellow box simulates the
image captured by a full-frame 35-mm sensor, while the red box simulates a smaller image from a crop sensor. (b) The image obtained using a full
frame sensor. (c) The image obtained using a crop sensor. Note the smaller sensor captures a smaller portion of the image and has the appearance of
using a longer focal length.
a
b
c

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also retain the detailed information in the brightest and darkest
portions, which are typically discarded with routine compression
algorithms in exchange for smaller file size.
File Storage and Backup
:ith digital images, the choice of file storage balances image
quality versus file size. File format and resolution impact imme-
diate utility, as well as future usability in publication.
In general, smaller files are easier to share and store but
have worse image quality and are not useful for editing due
to the loss of data during compression. Over time, with newer
technologies that support higher and higher resolution, such
as high-definition (HD) computer monitors, compressed files
appear obsolete and dated. Larger files, on the other hand,
retain as much data as possible and are more likely to be usable
with newer resolution standards. Even though they consume
more storage space, given the combination of high-speed
Internet and unlimited, secure compliant online storage that
complies with Health Insurance Portability and Accountability
Act (HIPAA) requirements for security and confidentiality,
uncompressed or raw files are no longer prohibitive to main-
tain. Such uncompressed raw files are more likely to be updated
and usable in 10 to 20 years.
Since photos are irreplaceable, it is recommended to back
up photo databases regularly with redundancy, optimally in a
separate geographic location in the event of a natural disaster.
Commonly this may be accomplished through a rotation of mul-
tiple encrypted hard drive backups that are stored in physically
different buildings. Alternatively, online cloud storage provides
redundancy, but care must be taken to ensure HIPAA compliance
within the online service. Furthermore, the permanence and
security of online storage cannot be taken for granted, and dupli-
cate physical hard drive backup is still recommended.
Camera Selection: Smartphone vs.
Point-and-Shoot vs. SLR
The optimal camera choice is ultimately personal preference,
balancing portability with image quality, assuming all security
and privacy requirements are met.
Smartphones are undoubtedly the most convenient and most
ubiquitous cameras available, with acceptable image quality
for general health care needs. Although some offer the ability
to take photos in a raw uncompressed format, image sharpness
has not yet reached the level required for publication. Patient
privacy remains the primary hurdle preventing widespread use
of smartphone use. Photos should not be stored locally on the
phone; instead, some electronic medical record (EMR) services
offer smartphone apps that allow encrypted uploading directly
to the service, bypassing local storage on the phone. It is crucial
to educate health care staff regarding the dangers and pitfalls of
photo sharing and social media using unauthorized smartphone
use in the clinical setting.
The image quality of smartphones will never equal that of
stand-alone cameras in the near future, simply due to the physics
involved, with sensor size and the quality of optical elements. In
terms of image crispness and dynamic range, the major determi-
nants are sensor size and quality, giving SLR (and mirrorless SLR)
cameras the advantage. Interchangeable lenses used with SLR
cameras offer the best performance. SLR cameras will beat point-
and-shoot cameras and smartphones in virtually every aspect
except for cost, convenience, and portability.
Point-and-shoot cameras provide a practical middle ground
between smartphones and SLR cameras. For clinical use, the most
useful cameras provide modes allowing the user to manually
select the desired shutter (shutter priority), aperture (aperture
priority), or both (program mode), also with the option to
select ISO (manual mode). This allows consistent, reproducible
Fig. 3.18 Comparison of dynamic range across varying levels of brightness in the human eye versus film and digital sensors. Film and sensors are
unable to distinguish among light levels at the extremes of intensity, and information is lost and appears as pure black or pure white within the image.

3 Photographic Essentials in Aesthetic Surgery
33
photographs to be taken across timepoints by using the same
aperture setting, for instance.
Protected Information and HIPAA Compliance
The ease of file sharing necessitates the utmost care to ensure
patient privacy and security. Identifiable features of photos
include showing the full face of the patient, tattoos, or any of
the 19 elements of protected health information, as shown in
Table 3.1. Of note, it is no longer acceptable solely to mask the
eyes. It is strongly recommended to obtain consent when using
any part of the face.
Photos must be stored in a HIPAA-compliant fashion. Digital
photos must be stored securely on encrypted hard drives. Since
most cameras and memory cards do not have password capability
or built-in encryption, it is crucial to download and delete media
from cameras regularly and in a timely fashion lest the camera be
lost or stolen. Furthermore, some file-keeping software includes
the patient’s name in the metadata of the photograph. In that case,
if the files are shared for any reason, the file name and metadata
should be cleared of any patient identifying information before
being shared.
Patient consent must be obtained for any use outside of a sur-
gical practice for treatment, payment, or healthcare operations.
Any external use of photos in conferences, seminars, or other
public areas requires patient consent. Photos that do not contain
identifiers do not require approval.
3.6 Photographic Standards in
Clinical Practice
Although there are many ways to photograph a subject using
various lighting styles or settings, a key tenet in clinical practice
is standardization and reproducibility, which allows comparison
across timepoints. :ith standardized and reproducible meth-
ods, the only aspect of the photos changing over time is the
patient. 1umerous authors have published their recommended
standards, but the guiding principle is to establish a standardized
system that can be performed and replicated identically over
time, with the same angles, lighting, backgrounds, and content.
Across timepoints, different areas of the body should be taken
from the same angles with the same focal lengths. Lighting should
be consistent, ideally using multiple sources of light to avoid
shadowing. Color balancing should be performed at the time
of photography or with postprocessing. Distractions should be
minimized, such as jewelry and certain clothing. In the operating
room, bloodstained skin should be cleansed; clean, dry towels
should be used to provide a uniform background; and lighting
should be standardized.
In general, facial photographs are best taken using portrait
lenses around 90 to 110 mm in focal length to minimize distortion.
:hen this is not possible, due to equipment or small examination
rooms, it is most helpful to step as far away from the subject as
possible and crop the image to create a rough equivalent to using
a portrait lens. Photos of the body and extremity are best taken
using ´normalµ lenses around 50 mm. :hen using a smartphone
or point-and-shoot camera, the best photos result from taking
several steps farther from the subject and ´zooming inµ on the
patient.
3.6.1 Standard Views for Regions of
Interest
The following sections briefly describe defined standards for
varying body regions of interest. A reference booklet is available
from the American Society of Plastic Surgeons and Plastic Surgery
Educational Foundation and is recommended for reference. In all
instances, distracting elements³jewelry, heavy makeup, hair,
etc.³should be removed. To minimize variation across time-
points, ideally the same location, lighting, camera position, and
patient positioning settings should be reproduced. Strategically
placed tape marks (or footprints) along the floor help expedite
positioning of the patient (Fig. 3.19a), and markings along the
wall direct the patient’s gaze. Standardized smooth, diffuse
lighting is readily available using commercially available soft-
boxes or umbrellas, as shown in Fig. 3.19b.
Facial photographs are typically taken using a portrait or
medium telephoto lens (85 mm to 135 mm) at a 1-meter distance
or farther, aiming to include the vertex to suprasternal notch
(Fig. 3.20). The patient should be aligned either along the Frankfort
plane (external auditory canal to the infraorbital rim) or the natural
horizontal facial line (patient subjectively looks forward at eye
level) (Fig. 3.21). The entire body should be rotated for oblique and
lateral views. To standardize oblique views, it is helpful to align
the nasal tip with the anterior border of the cheek. A standardized
basal view aligns the nasal tip with the upper lid crease.
Photographs of the eyes should include from the eyebrows
down to at least the upper lip to ensure inclusion of the orbitoma-
lar troughs. Aside from the typical angles, photos should include a
closed-eye view, upward gaze, and downward gaze.
1asal photographs should include the eyebrows and upper lip
as well. Additional views include a worm’s-eye view, cephalic
view, and views with dynamic contraction.
Lip photographs should be taken in repose, with the lips resting
and slightly parted. Oblique views can be reproduced by lining up
Table 3.1 Identifiable protected health information
IdenWiÀDEOe SrRWeFWed KeDOWK inIRrmDWiRn
'emRgrDSKiF inIRrmDWiRn
• Name
• Date of birth
• Address
• Telephone number
• Fax number
• Email address
0ediFDO inIRrmDWiRn
• Date of treatment
• Fingerprints or voiceprints
IdenWiÀFDWiRn numEerV
• Social Security number
• Medical record number
• Account number
• Driver’s license number
• Credit card number
• Health plan beneficiary number
• Vehicle/device serial number
SRFiDO inIRrmDWiRn
• Names of relatives
• Name of employer
• Website address
• Internet address of computer

34
I Fundamentals
the junction of the philtral column and vermilion with the contra-
lateral cheek. Pursed-lip views help in identifying vertical lip lines.
Views of the chest and breast should include the lower neck and
extend past the subcostal margin (Fig. 3.22). Arms may be placed
at the side, resting on the hips, or behind the back. For oblique
views, the arms should be moved posteriorly. Lateral views may
be standardized by ensuring that the chest/breast farther from the
camera is not visible.
Fig. 3.19 (a) Example of a floor diagram to direct patient positioning during photography. (b) Example of commercially available softboxes that
provide continuous neutral white light.
a
b
Fig. 3.20 Standardized views of the face. (a–e) The camera is on the plane of the Frankfort horizontal. The patient must turn the entire body
rather than just the head alone. The ears are used as reference to keep the head level. (f,g) Frontal close-up views of upper and lower facial halves.
(h) Worm’s-eye view.
a
b
c
d
e
f
g
h

3 Photographic Essentials in Aesthetic Surgery
35
The lower trunk and abdomen are photographed with the legs
at hip width, with feet parallel, including the inframammary fold
and extending to the upper thigh. Distracting clothing should
be replaced with standard disposable blue underwear. A diver’s
view³taken at a slightly oblique angle, with the patient stand-
ing with the torso flexed³highlights the abdominal soft tissue
(Fig. 3.23).
Lower extremities are shown completely from the umbilicus to
the toes or, alternatively, for a half-view, from the umbilicus to the
patella (Fig. 3.24), or from the patella to the toes. Ideally a lengthy
background should be used to extend from the background onto
the floor in a smooth, continuous fashion. If the feet are being
highlighted, a step stage is helpful. Lateral views may be standard-
ized by ensuring the farther leg is not visible.
3.6.2 Lighting Styles
Ideal lighting consists of using standardized, reproducible broad,
soft lighting to re-create even, smooth illumination from multi-
ple angles. However, outside of the office studio, this is impracti-
cal due to the amount of equipment and time required for setup.
There are several ways to arrange the photograph according to
the desired result, with a tradeoff between studio publication
appearance versus speed and convenience.
“Standard” Flash
For most circumstances in the clinic, on the ward, and intraop-
eratively, photos are best taken using flash. Hospital and clinic
rooms are often unevenly lit with overhead light that results in
unflattering shadows across the patient’s face and body. Little
light is available, requiring high ISO sensitivity with a large
aperture to attain adequate exposure, resulting in a grainy
photo with a shallow depth of field that may also be blurry due
to inadequate shutter speed. Overhead tungsten or fluorescent
lights frequently mask accurate skin tones and color. It is not
recommended to take photos solely using ambient light unless
alternatives are not available.
To compensate for poor ambient light, the on-camera or external
flash provides reproducible lighting appearance regardless of the
ambient light, creating a more uniform photo series comparison
preoperatively and postoperatively. Flash also provides sufficient
light, allowing for lower ISO sensitivity and smaller apertures
within the f/7 to f/9 range, creating crisper images with less noise
and a broader depth of field.
:ith flash photography, the position of the light source relative
to the lens affects the shadows cast upon the subject (Fig. 3.25).
:ith any angled or side view, the flash should be on the side of
the lens that is closer to the patient’s anterior to avoid uneven
distracting illumination.
Bounce and Ring Flash
A more advanced technique is to direct the flash away from
the patient, reflecting light off of the ceiling or a wall, referred
to as a ERXQFH ÁDVK. This more accurately emulates a broad
source of light, decreasing the appearance of harsh shadows.
Often a shoe-mounted flash on an SLR camera is needed for this
maneuver.
5LQJ ÁDVKHV are available and provide excellent high-intensity
light for macro photography. However, light is distributed so
evenly that shadows are eliminated and contours are difficult
Fig. 3.21 Effect of head position. (a) Frontal photograph taken in the proper plane. (b) The camera is below the Frankfort horizontal. (c) The camera
is above the Frankfort horizontal. Note the difference in the appearance of the overall height of the face, the amount of scleral show, and the
prominence of the nose and chin among other features. Note that in b and c, the angle of the face from the horizontal is less than 10°, yet it creates
obvious differences.
a
b
c

36
I Fundamentals
Fig. 3.22 (a–e) Standardized views of the breasts. Placement of the
hands on the hips for the lateral views is useful to show any postoper-
ative scars, the inframammary fold, and other features. Note that the
shoulders are aligned with the top of the photograph.
a
b
d
c
e
Fig. 3.23 (a–d) Standardized views of the lower trunk and abdomen.
The diver’s view (d) highlights the abdominal soft tissue.
a
c
b
d
Fig. 3.24 (a–e) Standardized half-view of the (upper) lower extremity.
a
b
c
d
e
Fig. 3.25 The flash position relative to the lens casts differing shadows
and should be mounted on the same side of the lens as the patient’s
anterior. The top row shows a frontal view with the flash mounted to
the right (a), left (b), and above (c) the patient. Note the distracting
shadows cast with the flash mounted toward either side. The bottom
row shows a lateral view with the flash mounted toward the patient’s
posterior (d), anterior (e), and superior (f).
a
d
b
e
c
f

3 Photographic Essentials in Aesthetic Surgery
37
to discern. These flashes are useful for close-ups of detail or
difficult-to-illuminate areas, such as with dental or dermatologic
purposes, but are not typically used to photograph the body or
extremities.
3.6.3 ´SWudiR (̵eFWµ 3KRWRgrDSKy
Certain instances call for meticulous photographs with back-
grounds completely free from distraction and evenly illuminated
details. Setup requires multiple light sources at varying angles
for elimination of harsh shadows. Backgrounds are meticulously
neat without distraction or reflection, such as with a velvet
background or a plain blue wall (Fig. 3.26).
Alternatively, the background can be eliminated completely as
in Fig. 3.27. This studio effect is accomplished by illuminating the
subject with high-intensity light while providing as little light
as possible to the background, table, and nearby elements. By
properly metering the photograph to the well-lit subject, typically
with the aid of center- or spot-metering, the background and
other elements appear far underexposed in relation and appear
black. This effect is best accomplished when the background and
floor are as far from the subject as possible, since less light will
reflect from the subject and provide less illumination.
Focused high-intensity light can be accomplished with external
flashes or spotlights. Operating room overhead lights function
well as spotlights and, when carefully aimed at the subject, can
provide sufficient lighting, as in Fig. 3.11. Lights should be aimed
to create smooth, even lighting. It is sometimes helpful to move
lights farther from the subject to allow greater diffusion of the
spotlight.
3.6.4 Intraoperative Photography
Intraoperative photography can be divided into two types:
staged and nonstaged, ´actionµ shots.
:ith appropriate staging, distractions are removed from the
operative field, including instruments and cables, as shown in
Fig. 3.28. Blood is wiped clean from the area. The area of inter-
est is surrounded using clean, dry operative towels to mask the
wrinkled, blood-speckled operative drapes. If flash is used, then
the operative lights should be removed from the field because of
uneven light intensity and difference in light temperature and
hue. Alternatively, operative lights may be used as spotlights
without the use of flash.
Staging of photographs can be time-consuming and disruptive
to the flow of the procedure. Alternatively, ´actionµ shots taken
throughout the procedure capture key steps and fine detail with-
out repeated pauses. Results are best with telephoto lenses and
center- or spot-metering and overhead operative light, as shown
in Fig. 3.29.
3.7 Concluding Thoughts
Photography remains one of the most essential tools available
to a plastic surgeon. Mastery of fundamental principles under-
lying photographic exposure permits skillful use of advanced
concepts, allowing the eye-catching capture of crucial details.
Understanding the technological evolution in photography
permits postprocessing corrections to bring the photographs
Fig. 3.26 A simple blue background with evenly-distributed soft
lighting from multiple directions creates a pleasant appearance
without distracting shadows.
Fig. 3.27 An example of a textbook-style/studio-style photograph
with an absent background. This example shows medial femoral
condyle free flap anatomy prior to harvest.
Fig. 3.28 An example of a staged intraoperative photograph. The
operative field has been cleansed, and the tendon grafts are lined up
next to the hand.

38
I Fundamentals
to true-to-life appearance for the sake of anything from plain
documentation to portfolio marketing or publication. As tech-
nology continues to evolve, novel considerations will undoubt-
edly arise, but fortunately the underlying concepts will endure
perpetually.
Clinical Caveats
• The most useful clinical photographs are taken in a reproduc-
ible fashion using standardized patient positioning, lighting,
and camera settings.
• Proper focal length should be chosen to minimize perspec-
tive distortion while using appropriate shutter speed and
aperture to prevent motion blur and maintain a broad depth
of field.
• The most reliable lighting is provided using external lighting
(flash or light boxes) or overhead lights arranged purposefully.
• Simple postprocessing correction of white balance and
exposure can dramatically improve the appearance and
consistency of clinical photos.
• Camera choice is a personal preference, weighing convenience
and portability versus image quality, camera size, and cost.
• All digital information should be stored in a protected, HIPAA-
compliant fashion, ideally with multiple redundant backups.
Higher-resolution files are recommended if practical.
• Adequate camera sensor resolution for publication is a lesser
concern now, as newer cameras have far greater resolution
than necessary.
• Facial photographs are best taken with a portrait lens of
around 90- to 110-mm focal length to minimize distortion.
• When using a smartphone or point-and-shoot camera, the
best results are achieved by stepping back from the subject
and zooming in.
Suggested Reading
>1@ American Society of Plastic Surgeons. Photographic Standards in Plastic Surgery.
Arlington Heights, IL: Plastic Surgery Educational Foundation; 2006
>2@ Hoffman :<. Photography in plastic surgery. In: Hentz VR, Mathes S-, eds. Plastic
Surgery. 2nd ed. Philadelphia, PA: Elsevier; 2006:151–165
>3@ .inney BM. Photography in plastic surgery. In: 1eligan PC, :arren R-, eds. Plastic
Surgery. Vol. 1: Principles. 3rd ed. 1ew Fig. 3.29 An intraoperative “action shot” that does not disrupt the
flow of surgery. In this case, a cross-finger flap is being harvested.
The wispy, loose areolar tissue and fine capillaries are visible and not
overblown through the correct use of metering and exposure.

 3DWienW SDIeWy in AeVWKeWiF Surgery
39
4 Patient Safety in Aesthetic Surgery
Christopher A. Tokin, Christodoulos Kaoutzanis, Kent K. “Kye” Higdon, and James C. Grotting
Abstract
Patient safety in aesthetic surgery is a dynamic and complex
topic that is a core concern for any cosmetic practice. It rep-
resents a complex interaction between balancing medical risk
factors, minimizing morbidity, preventing medical errors, and
optimizing patient care. In this chapter we review guidelines
and recommendations set forth by major professional societies
and review the literature specific to aesthetic surgical patients.
Understanding patient-specific risk factors that increase mor-
bidity enables surgeons to perform risk stratification appropri-
ately. Reviewing guidelines related to prevention and treatment
of common surgical morbidities enables improved quality and
optimal outcomes.
Keywords
plastic surgery, aesthetic surgery, cosmetic surgery, patient
safety
4.1 Introduction
Patient safety represents a complex interaction between bal-
ancing medical risk factors, minimizing morbidity, preventing
medical errors, and optimizing patient care. Every plastic
surgeon must be adept at appropriate patient selection and
risk management and be well-versed in guidelines and policies
that enhance patient safety. Many of these guidelines and rec-
ommendations are not taught and are not specific to aesthetic
surgery. :e collect methodology from other medical disciplines
to create evidence-based guidelines so as to manage risk
effectively, especially in this special subset of patients in whom
elective procedures are being performed. Recently, several large
databases have become available for collection of outcome data
specific to the aesthetic surgery population. This has allowed
more accurate identification of important risk factors applicable
to these patients and this specific subset of procedures. It is with
this continued enthusiasm that we can optimize patient safety
in aesthetic surgery.
The landmark report To Err is Human: Building a Safer Health
System, issued by the Institute of Medicine in 1999, identified
preventable medical errors as an obstacle to patient safety. This
report estimated that approximately 44,000 to 98,000 Americans
died annually secondary to preventable medical errors, costing
the health care system over 79 billion. It defined medical error as
“the failure to complete a planned action as intended or the use of
a wrong plan to achieve an aim,µ and it concluded that more than
half of surgical adverse events are preventable. It was in response
to this that the patient safety movement was founded. Large
public health agencies such as the Centers for Disease Control and
Prevention (CDC), :orld Health Organization (:HO), Centers for
Medicare and Medicaid Services took on the task of improving
quality and safety in health care.
The amount of information regarding patient safety is stag-
gering. Luckily, the national plastic surgery professional associa-
tions³the American Society for Aesthetic Plastic Surgery (ASAPS)
and the American Society of Plastic Surgeons (ASPS)³have created
easily accessible documents and consensus statements regarding
the most important patient safety initiatives. It is these guidelines,
as well as the evidence available to support their adoption in
aesthetic surgery, that we will review in this chapter.
4.2 Patient Selection:
Risk Management
In order to optimize outcomes and minimize risk, appropriate
patient selection is imperative. During the initial consultation,
it is important to recognize the patient’s behavior and identify
warning signs that may affect ultimate patient satisfaction (such
as fixed psychological or social problems or defensive manner-
isms). At the same time, it is the surgeon’s responsibility to assess
the suitability for ambulatory plastic surgery. This involves
a complete history and physical exam, including important
patient-specific risk factors such as age, gender, body mass index
(BMI), smoking status, and other complicating medical factors
that could affect morbidity. Most of these factors will each be
discussed separately later in the chapter. The preoperative con-
sult must also include strategies to enhance the perioperative
process, including documented informed consent, adequate
photo documentation, a review of postoperative expectations,
compliance with postoperative instructions, and a pregnancy
test on female patients of childbearing age.
4.3 Patient Selection:
Patient-Related Risk Factors
A complete preoperative history and physical exam can easily
identify patient-specific risk factors that can increase the risk
of intraoperative adverse events and postoperative complica-
tions. Identifying these risk factors as they relate to aesthetic
procedures and quantifying how they impact adverse events
are important. In 2009, the ASPS Patient Safety Committee
published evidence-based guidelines regarding patient selection
and procedures in ambulatory surgery. It has made recommen-
dations and graded them based on the strength of the supporting
data (Table 4.1). In subsequent years, our group has had the
opportunity to publish extensively on how many of these patient
characteristics and comorbidities specifically affect the aesthetic
surgical patient and how they relate to complications following
specific aesthetic procedures.

40
I Fundamentals
4.3.1 Age
Adults over the age of 65 represent approximately 13 of the
current population in the United States, and the number of
elderly people seeking aesthetic procedures is increasing. There
has been conflicting evidence that older age contributes to
intraoperative or postoperative risk in the ambulatory surgery
setting. Increasing age is often associated with increased comor-
bidities, but age alone should not constitute a contraindication to
ambulatory surgery. In one of our previous studies that used the
CosmetAssureTM database to assess age as an independent risk
factor for postoperative complications, we found a major com-
plication rate of 2.2 in octogenarians, a number comparable
to younger cohorts. Other studies have shown that individuals
older than 65 years were 1.4 times more likely to experience an
intraoperative event and 2.0 times more likely to experience an
intraoperative cardiovascular event; however, this risk is depen-
dent on the patient’s overall health, the presence and severity of
cardiovascular disease, and the nature of the surgical procedure.
In conclusion, while age may increase the presence of comorbid
conditions, age alone does not appear to be an independent risk
factor in cosmetic surgery when these factors are controlled for.
4.3.2 Gender
Gender-based disparities in surgical outcomes have long been
documented across several disciplines. It has been shown that
men are more likely to have higher morbidity and mortality
following operative treatment of hip fractures, higher incidence
of pneumonia after blunt trauma, and increased peripheral
neurovascular complications secondary to diabetes. surgical literature evaluating clinical outcomes of cosmetic
surgery in men is limited. Our group has recently shown that
men demonstrate a similar overall complication rate compared
to women. However, when specific complications were analyzed,
men appeared to have significantly higher hematoma rates but
a lower incidence of surgical site infections. This was especially
true for facelift procedures in men versus women (1.4 vs 0.5).
This has been supported by other large-volume studies that
suggest that the relative risk of hematoma in male patients is as
high as 3.86 compared with females. On multivariate analysis,
independent predictors of major complications in men include
BMI greater than 25 kg/m2 (relative risk >RR@ 1.05; p  0.01),
procedures performed in hospital-based settings as opposed
to office-based procedures (RR 3.47; p  0.01), and combined
procedures (RR 2.56; p  0.01). In conclusion, aesthetic surgery
in men is safe, with low complication rates comparable to those
in women. Care must be taken to achieve excellent hemostasis,
as men have a higher risk of hematoma. Modifiable predictors
of complications to consider are BMI and combined procedures.
4.3.3 Body Mass Index
1early 70 of adults in the United States are overweight or obese
(BMI greater than 25 kg/m2), and this constitutes over a third of
patients seeking cosmetic surgical procedures. Obesity is not just
an epidemic of the current era; more important, it is associated
with cardiovascular disease, diabetes, hypertension, obstructive
sleep apnea, and increased infections. Studies have also shown
that obesity correlates with failed regional anesthetic block,
unplanned hospital admissions, and respiratory complications.
Our group has shown that not only does obesity increase com-
plication rates, but these rates also increase with increasing BMI
(Fig. 4.1). Specifically, surgical site infections, venous throm-
boembolism (VTE), and pulmonary dysfunction were twice as
common among overweight patients. Complications following
abdominal and body contouring procedures, or combinations
of breast and body procedures, were also significantly higher.
On multivariate analysis, we found that being overweight (BMI
25–29.9 kg/m2) and obese (BMI ! 30 kg/m2) were independent
risk factors of any complication, especially surgical site infection
and VTE. Mechanisms by which obesity affects surgical morbid-
ity and mortality are not entirely clear. However, the proinflam-
matory state is promoted by extra adipose tissue and may foster
an environment that makes patients susceptible to injury in
times of stress. Local wound complications in obesity have also
been well documented. Reviews of abdominoplasty and breast
reduction patients have found higher rates of wound dehiscence
and seroma. Obesity and venous thromboembolism also have a
known relationship. In the Caprini risk assessment model, which
Table 4.1 Scale for grading recommendations
Grade
Descriptor
4uDOiIying eYidenFe
ImSOiFDWiRnV IRr SrDFWiFe
A
Strong recommendation
Level I evidence or consistent findings from
multiple studies of levels II, III, or IV
Clinicians should follow a strong recommendation unless a clear
and compelling rationale for an alternative approach is present
B
Recommendation
Level II, III, or IV evidence and findings are
generally consistent
Generally, clinicians should follow a recommendation but
should remain alert to new information and sensitive to patient
preferences
C
Option
Level II, III, or IV evidence, but findings are
inconsistent
Physicians should be flexible in their decision making regarding
appropriate practice, although they may set bounds on
alternatives; patient preference should have a substantial
influencing role
D
Option
Level V: little or no systematic empirical
evidence
Clinicians should consider all options in their decision making and
be alert to new published evidence that clarifies the balance of
benefit versus harm; patient preference should have a substantial
influencing role
Data from American Society of Plastic Surgery, Grading Recommendations, available at

 3DWienW SDIeWy in AeVWKeWiF Surgery
41
has been validated for use in plastic and reconstructive surgery,
BMI greater than 25 represents an independent risk factor and
may be used as a factor when considering pharmacologic VTE
prophylaxis. In conclusion, BMI has a direct and proportional
relationship to the incidence of both minor and major complica-
tions following aesthetic surgery.
4.3.4 Smoking
All patients should be asked about their smoking history as
well as their exposure to second-hand smoke. Smoking is a
well-established risk factor for atherosclerotic disease and has
been shown to increase the overall risk of complications in
plastic surgery. Smoking can lead to increased production and
activation of fibrinogen and has been associated with VTE. It also
alters the microcirculation and can compromise flap survival.
Many plastic surgeons do not offer certain aesthetic procedures
to smokers, and the ASPS evidence-based recommendations
encourage smoking cessation anywhere from 24 hours to 6 to
8 weeks before surgery (Grade B Recommendation) and up to
7 days following surgery (Grade D Recommendation). The CDC
recommends smoking cessation at least 4 weeks before surgery.
Patient compliance with smoking cessation can be ensured by
blood, urine, or saliva test and is encouraged.
4.3.5 American Society of
Anesthesiologists Status
The American Society of Anesthesiologists (ASA) status has been
accepted as the standard for assessing preoperative condition
(Table 4.2). Patients should be assigned an ASA classification, and
this should be used for risk stratification. Large, hospital-based
ambulatory surgery studies have shown that ASA II or III was
a predictive factor for unanticipated hospital admission that
increased the risk over twofold. Other retrospective studies have
shown that risk significantly increased between ASA class II and
III. Many cosmetic surgeons feel that a patient with an ASA class
of IV is not suitable to undergo elective cosmetic surgery. This is
in line with ASPS evidence-based recommendations, which state
that patients categorized as ASA class I to III can be considered
for ambulatory surgery (Grade B Recommendation).
4.3.6 Diabetes Mellitus
Diabetes mellitus is a common chronic disease affecting 9, or
29 million, of the U.S. population and is considered a risk factor
for a variety of perioperative adverse events. Diabetics are nearly
twice as likely to be overweight or obese as nondiabetic patients
and are at higher risk of infection due to impaired immune func-
tion secondary to hyperglycemia. Studies have demonstrated
decreased granulocyte function and microbicidal action in
diabetics. Complications from hyperglycemia can be reduced
with improved glycemic control; however, optimal perioperative
glucose targets have not been established, and highly intensive
insulin regimens are associated with minimal benefits and the
risk of hypoglycemia.
Our group has shown that in aesthetic surgery patients, dia-
betics have significantly more complications than nondiabetics
(3.1 vs 1.9, p  0.01), especially in body cases, most notably
abdominoplasty (Fig. 4.2). Diabetics were also more likely to have
wound infections and pulmonary complications. In conclusion, a
preoperative diagnosis of diabetes mellitus is an independent risk
factor for complications in the aesthetic surgery patient. It is pru-
dent to set the right expectations in the preoperative period by
notifying diabetic patients of their increased risk of complications,
reviewing and optimizing their hemoglobin A1c, and ensuring
adequate glucose control in the perioperative period.
4.3.7 Obstructive Sleep Apnea and
Obstructive Lung Disease
The significance of obstructive sleep apnea in the ambulatory
surgery setting is unclear, largely because it is difficult to sep-
arate the effects of surgery from the consequence of apnea. In
addition, the diagnosis of obstructive sleep apnea often coincides
with other comorbidities, such as obesity, hypertension, and dia-
betes. However, retrospective studies comparing patients with
obstructive sleep apnea to those without, controlling for other
comorbid conditions, have shown no difference in the rate of
unplanned hospital admissions. 1evertheless, the ASA guidelines
Table 4.2 American Society of Anesthesiologists physical status
classification
Class
'eVFriSWiRn RI VWDWuV
ASA I
Normal, healthy
ASA II
Mild systemic disease
ASA III
Severe systemic disease
ASA IV
Severe systemic disease that is a constant threat to life
ASA V
Not expected to survive without the operation
ASA VI
Organ donor
Data from the American Society of Anesthesiologists, available at
asahq.org/standards-and-guidelines/asa-physical-status-classification-system.
Fig. 4.1 Major complications stratified by body mass index (BMI)
category. VTE: venous thromboembolism.

42
I Fundamentals
state that patients with prior diagnosis of obstructive sleep
apnea have an increased risk for respiratory depression and may
require longer postoperative monitoring. Respiratory depression
is more prominent with general anesthesia and postoperative
opioid use. For this reason, the ASPS evidence-based recommen-
dations reflect the ASA guidelines and state that patients with
a diagnosis of obstructive sleep apnea are at increased risk of
perioperative complications and are generally not appropriate
candidates for procedures in free-standing outpatient settings
(Grade D recommendation). In addition, systemic opioids should
be avoided, continuous supplemental oxygen should be strongly
considered, and continuous positive airway pressure (CPAP)
machines should be utilized.
:ith regard to obstructive lung disease, patients may be
considered appropriate in the ambulatory setting if they are free
from symptoms and have optimal lung function documented
preoperatively. If patients have symptoms, elective surgery
should be postponed, and patients should be free from steroid
therapy for at least 6 months prior to elective surgery (Grade D
recommendation).
4.3.8 Cardiovascular Conditions
There is evidence in the literature indicating that patients
affected by various cardiovascular conditions, such as heart
disease, stroke, or hypertension, are at increased risk for
intraoperative hemorrhage and postoperative complications in
the ambulatory setting. According to the American College of
Cardiology guidelines, patients with active cardiac conditions
should be treated and cleared prior to undergoing elective sur-
gery. However, those with remote/prior myocardial infarction
(! 6 months), 1ew and asymptomatic valvular disease can be considered for ambu-
latory surgery. Patients with cardiovascular conditions are often
on anticoagulation. :hile some studies have shown that contin-
ued aspirin use (75–300 mg) before surgery is an independent
risk factor for intraoperative and postoperative bleeding, the
increase in bleeding duration and severity is small. Risks and
benefits are likely patient-specific and directly related to the
procedure at hand and should be discussed with the patient pre-
operatively. Patients on other anticoagulation therapies, such as
warfarin or clopidogrel, are likely at higher bleeding risk. Many
of these patients can be safely bridged on some form of heparin
therapy, but these decisions should be made in conjunction with
a cardiologist, as stopping anticoagulation for any period of time
may be unsafe in this specific patient subset.
4.4 Patient Selection:
Postoperative Complications
Patient-specific risk factors, in combination with certain aes-
thetic procedures or groups of aesthetic procedures, may put
patients at increased risk of particular postoperative complica-
tions, the most common being surgical site infection, hematoma,
and life-threatening VTE. Our group has been able to use a
large, prospectively maintained insurance database of aesthetic
surgery patients to gather outcome data to assist in identifying
particular subgroups at risk. In this way, we hope to assist plastic
surgeons with patient selection and informed consent.
4.5 Surgical Site Infection
Surgical site infections represent one of the most common post-
operative complications in patients undergoing aesthetic surgery,
and while overall incidence is low, the potential outcome for the
cosmetic patient can be devastating. The role of perioperative
antibiotics in preventing surgical site infection is clear, and they
are utilized to target the most likely contaminant. Most often, a
first-generation cephalosporin is used, given anywhere from 30
to 60 minutes before incision is made. Alternative antibiotics are
chosen based on risk factors and patient allergies.
It is important to understand the incidence and risk factors for
major surgical site infections, in order to be able to risk-stratify
patients, as well as prepare to intervene when necessary. Our group,
again using the large, prospectively maintained CosmetAssureTM
database of exclusively aesthetic surgery patients, found the
incidence of major surgical site infections requiring emergency
room visit, hospital admission, or reoperation to be low (0.46).
:ound infections were more likely in smokers, who had a 61
increase in risk compared to nonsmokers. These findings have
been duplicated among multiple surgical specialties. Smoking
can affect the microenvironment of the tissue through nicotine’s
vasoconstrictive and hypoxic effect and potentially compromise
all phases of wound healing. In randomized controlled trials,
smoking cessation for at least 4 weeks prior to surgery was asso-
ciated with reduced infectious complications, potentially due to
improvement in inflammatory cell and host defense functions.
Diabetes mellitus has inconsistently been reported as a risk
factor specific for surgical site infections, but our group found
that diabetes increased the risk for major wound infections in
cosmetic surgery patients by 58. :hile it is unclear whether
Fig. 4.2 Major complications in diabetic versus nondiabetic patients
following aesthetic surgery on different body regions. Breast proce-
dures include augmentation, mastopexy, reduction, and gynecomastia
correction. Body procedures include buttock lift, calf implant, labi-
aplasty, lower body lift, thigh lift, brachioplasty, and upper body lift.
Face procedures include blepharoplasty, brow lift, cheek implant, chin
augmentation, facelift, facial resurfacing, hair replacement, otoplasty,
and rhinoplasty. Numbers in red indicate statistical significance with p
< 0.05.

 3DWienW SDIeWy in AeVWKeWiF Surgery
43
this is related to perioperative glucose control, we continue to
recommend obtaining a hemoglobin A1c as part of the medical
clearance (ideally less than 7). :hile cosmetic surgery can safely
be performed on diabetics, patients should be warned of their
increased risk for complications, especially in body procedures, as
mentioned previously.
Trunk and extremity procedures were an independent risk
factor for major surgical site infections on multivariate analysis; in
fact, trunk and extremity procedures were the strongest predictor
of wound infections of any independent risk factor, with a relative
risk of 2.42. Of note, in our analysis, the majority of patients (68)
underwent a combined procedure. Combined procedures had
a relative risk of 1.88, which was statistically significant. Even
though the increase in complication rate in combined procedures
is less than the sum of the complication rates of each procedure
done separately, it still requires careful consideration. There was
a trend toward a higher surgical site infection rate with each
additional region added to the operation (Table 4.3). It should
be noted that our group did not control for operative time, which
has been shown in numerous other studies to be an independent
variable associated with increased surgical site infections and is
logically lengthened with combination procedures.
4.5.1 Hematoma
Hematoma is another very common complication in aesthetic
surgery patients. In a previous study of 129,007 patients under-
going cosmetic procedures, multivariate analysis showed age,
male gender, combined procedures, and procedures performed
on the breast to be independent risk factors for developing major
hematomas requiring emergency room visit, hospital admission,
or reoperation. :hile our group has shown that aesthetic surgery
is safe in the elderly, the data shows that advancing age can be an
independent risk factor for hematoma development. This could
be related to undiagnosed or untreated hypertension, or higher
ASA class, which was not specifically looked at by the study.
Gender has also been previously identified as a risk factor for
the development of postoperative hematoma in different plastic
surgery populations, specifically breast surgery, facelift, and body
contouring procedures. Male gender had a relative risk of 1.98 for
major hematoma in our analysis.
Combined procedures and breast procedures were additional
independent predictors for hematoma development. However,
BMI, smoking, and diabetes, which are risk factors for overall
complications, did not show significance with the development of
hematoma specifically.
4.5.2 Venous Thromboembolism
VTE, including both deep venous thrombosis (DVT) and pulmo-
nary embolism (PE), remains one of the most feared complica-
tions in all of medicine. In the postsurgical patient, the period
of highest risk for fatal PE is within the first 3 to 7 postoperative
days, with the estimated 28-day mortality for a first episode of
VTE being 11. The American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF) reported that between
-anuary 2001 and -une 2006, there were 23 deaths among approx-
imately 1 million outpatient aesthetic surgery procedures, 134 of
which resulted from PE (57). The procedure with the highest
rate of postoperative mortality was abdominoplasty, followed by
facelift surgery in combination with other procedures.
In 2008, the release of a report by the Surgeon General’s office
identified VTE as one of the leading public health problems. It
stated that 20 of people with PE die, and postoperative surgical
patients are at highest risk up to 3 months following surgery. In
response, the ASPS created the Venous Thromboembolism Task
Force to assist plastic surgeons in implementing best practices
for VTE prevention. Among these was endorsement of the 2005
Caprini Risk Assessment Scale, which has been validated for use in
plastic surgery patients and is now the most commonly used tool
in cosmetic surgery to assess a patient’s VTE risk profile (Fig. 4.3).
In the Caprini model, VTE risk factors are assigned points, and the
points are added to assess overall risk. The ASPS follows with rec-
ommendations on anticoagulation strategies based on the Caprini
score (Fig. 4.3). Most notably, a score as low as 3 is considered
an indication for use of postoperative chemical chemoprophylaxis
(Grade B recommendation), and a score of 7 or more should be
an indication to strongly consider using extended postoperative
chemical prophylaxis (Fig. 4.4). This is in accordance with the
American College of Chest Physicians (ACCP) recommendations
that all surgical patients receive mechanical and chemoprophy-
laxis for venous thromboembolism unless they are undergoing a
minor procedure or have a high risk of bleeding. The variety of
procedures and what defines ´minorµ surgery in the aesthetic
surgical patient make studying VTE in this population especially
difficult.
One of our previous studies examined 129,007 aesthetic surgi-
cal patients and found the rate of major VTE to be 0.09. Age and
BMI were found to be the only significant patient characteristics
that were predictors for VTE. Smoking and diabetes were also
evaluated but not found to be risk factors. This is inline with the
Caprini model, which assigns both age and BMI one point but does
not include smoking or the diagnosis of diabetes in their model.
In multivariate logistic regression analysis, body procedures and
combined procedures were found to increase the risk of VTE most
significantly (Fig. 4.5). The ACCP data and the Caprini model do not
Table 4.3 Incidence of surgical site infections among different
procedure combinations per body region(s), stratified by gender
Body region(s)
Surgical site
inIeFWiRn
Surgical site
inIeFWiRn
mDOe
Surgical site
inIeFWiRn
IemDOe
Face
34 (0.2%)
5 (0.2%)
29 (0.2%)
Breast
143 (0.2%)
1 (0.1%)
142 (0.3%)
Body
266 (0.8%)
14 (0.5%)
252 (0.9%)
Face + Breast
5 (0.4%)
0
5 (0.4%)
Face + Body
15 (0.6%)
2 (0.7%)
15 (0.6%)
Breast + Body
132 (1.0%)
2 (0.3%)
130 (1.0%)
Face + Breast + Body
4 (0.9%)
1 (5.9%)
3 (0.7%)

44
I Fundamentals
look specifically at plastic surgery procedures. However, smaller
studies have shown that abdominoplasty specifically, as well as all
body procedures, increases the risk of VTE significantly, compared
with procedures performed on other body locations such as breast
and face. :e have also shown that face procedures, breast proce-
dures, or combining face and breast procedures confers an overall
low risk of VTE. However, body procedures, or any combinations
that include body procedures, impose greater risk. In conclusion,
while the overall incidence of VTE in cosmetic procedures is rel-
atively low, the risk increases with BMI and age, as well as with
combined procedures involving trunk and extremities.
4.6 Safety of Combining
Aesthetic Procedures
Combining procedures is common practice in aesthetic surgery,
not only because it reduces cost and improves efficiency but
also because multiple procedures may be needed for a more
balanced overall result or because patients desire multiple areas
to be addressed. Our group has shown that because the inci-
dence of major complications is relatively low in the aesthetic
surgical patient, the cumulative risk of multiple procedures is
Fig. 4.3 American Society of Plastic Surgeons thrombosis risk factor assessment, adopted from the 2005 Caprini Risk Assessment Model.

 3DWienW SDIeWy in AeVWKeWiF Surgery
45
often acceptable, and not directly additive. :e have shown, as
mentioned in prior sections of this chapter, that certain patient
characteristics, such as elevated BMI, can increase the risk of
both individual and combined procedures. :e have also shown
that the risk of these complications in combined procedures
increases when the trunk and extremities are involved. 1ow that
we have been able to define these additive risks, they should be
adequately disclosed to our patients as part of our preoperative
discussion and informed consent.
4.7 SDIeWy RI 2ffiFe-%DVed
Procedures
Over the past decade, there has been a dramatic rise in office-
based surgery across surgical subspecialties, particularly in aes-
thetic surgery. According to the American Society of Aesthetic
Plastic Surgery (ASAPS), there was over a 5 increase in office-
based cosmetic procedures from 56.3 to 61.9 from 2014 to
ASPS VTE Task Force
Risk Assessment and Prevention Recommendations
Approved by the ASPS Executive Committee in July 2011
Step 1: Risk Stratification
Step 2: Prevention
Patient Population
Patient Population
2005 Caprini
RAM Score
Recommendations
The scores Based apply to the 2005 Caprini RAM
and were not intended for use with alternative VTE risk
assessment tools
Recommendation
Should complete a 2005 Caprini RAM risk factor assessment tool
in order to stratify patients into a VTE risk category based on their
individual risk factors. Grade B
Or
Should complete a VTE risk assessment tool comparable to the
2005 Caprini RAM in order to stratify patients into a VTE risk category
based on their individual risk factors. Grade D
In-patient adult aesthetic and reconstructive plastic surgery who
undergo general anesthesia
Should consider completing a 2005 Caprini RAM risk factor assessment
tool in order to stratify patients into a VTE risk category
based on their individual risk factors. Grade B
Or
Should consider completing a VTE risk assessment tool comparable
to the 2005 Caprini RAM in order to stratify patients into a VTE risk
category based on their individual risk factors. Grade D
Out-patient adult aesthetic and reconstructive plastic surgery who
undergo general anesthesia
Elective Surgery Patients
(when the procedure is
scheduled in advance and
is not performed to treat
an emergency or urgent
condition)
Patients undergoing one
of the following major
procedures when performed
under general anesthesia
lasting more than 60 minutes:
• Body contouring,
• Abdominoplasty,
• Breast reconstruction,
• Lower extremity procedures,
• Head/neck cancer procedures
Should consider utilizing risk reduction strategies such as limiting
OR times, weight reduction, discontinuing hormone replacement
therapy, and early postoperative mobilization. Grade C
Should consider the option to utilize mechanical prophylaxis
throughout the duration of chemical prophylaxis for non-ambulatory
patients. Grade D
Should strongly consider the option to use extended LMWH
postoperative prophylaxis. Grade B
7 or more
3 to 6
3 or more
7 or more
Fig. 4.4 ASPS Venothromboembolism (VTE) Task Force risk assessment and prevention recommendations (based on 2005 Caprini Risk Assessment
Model).

46
I Fundamentals
2015. Guidelines and regulation to assist with safety exist in only
31 states, and regulations often vary from state to state. As part
of the regulatory process, some states require accreditation from
one of the three accreditation agencies: the -oint Commission on
Accreditation of Healthcare Organizations (-CAHO, often referred
to simply as the -oint Commission), the American Association
for Accreditation of Ambulatory Surgery Facilities (AAASF), and
the Accreditation Association for Ambulatory Healthcare. Much
of the published literature regarding the safety of office-based
surgery is limited to surveys, single-practice/surgeon retrospec-
tive reviews, or noncosmetic literature. Using the CosmetAssure
database, our group looked at over 129,000 patients (183,914
procedures), 57.4 of whom had procedures done at ambulatory
surgery centers (ASCs), 26.7 at hospitals, and 15.9 at office-
based surgery suites (OBSS). Complication rates were lowest
at OBSS (1.3), as compared with ASCs and hospitals (1.9 and
2.4, respectively). On multivariate analysis, there was a lower
risk of developing a complication in an OBSS compared to an ASC
(RR 0.67, 95 confidence interval >CI@ 0.59–0.77, p  0.01). These
results are in line with other published studies that conclude
that office-based surgery by board-certified or eligible plastic
surgeons is safe and of relatively low risk. The most common
complications were hematoma and infection. It should be noted
that patients with significant comorbidities, generally reflected
in ASA, may be preferentially treated in the hospital setting,
possibly contributing to higher complication rates observed in
hospitals; however, it is generally noted that most patients with
higher ASA classifications (III, IV) may not be suitable candidates
for elective cosmetic surgery at all. This study adds validity to
other published studies and suggests that procedures performed
in OBSS are generally safe. This is especially true in the setting of
appropriate accreditation and sound clinical judgment.
4.8 Perioperative Considerations
Any conversation regarding perioperative patient safety would
not be complete without discussing the importance of com-
munication in the operating room and the adoption of crew
resource management as a method to improve communication,
reduce errors, and improve patient safety. In addition, important
issues regarding perioperative patient safety include appropriate
patient positioning, adequate skin preparation, prevention of
hypothermia, and being prepared to manage crisis situations,
most notably malignant hyperthermia.
4.8.1 Communication at Fault
In 2006, the -oint Commission reported that 70 of all sentinel
events in health care were caused by communication failures.
1ow communication failures are largely touted as being the
most common, and likely most modifiable, preventable cause of
medical error. Communication errors likely involve verbal com-
munication between two people but can also include ambiguity
about delegation of responsibility.
4.8.2 Crew Resource Management
and Checklists
Crew resource management, adopted first in the aviation indus-
try, has been shown to improve performance, safety, commu-
nication, and morale as well as to decrease incidents related to
crew error. The concept was designed after the industry realized
that anywhere from 50 to 80 of significant aviation incidents
were caused by human rather than mechanical error. The Federal
Aviation Administration defines crew resource management
as ´an active process by crew members to identify significant
threats to an operation, communicate them to a person in charge,
and to develop, communicate, and carry out a plan to avoid or
mitigate each threat.µ
Adopting from successful safety practices in the aviation indus-
try, the -oint Commission and :HO have developed a universal
protocol and surgical checklist to assist hospitals and organiza-
tions improve system-based practices and patient safety (Fig. 4.6).
The ´Safe Surgery Saves Lives Challenge,µ which included adop-
tion of the :HO surgical checklist, was prospectively studied and
showed a significant decrease in death rate from 1.5 to 0.8, and
in complication rate from 11 to 7, after implementing use of
the checklist.
4.8.3 Patient Positioning
Patient safety regarding positioning cannot be overlooked.
Advanced age, extremes of body habitus, poor nutritional status,
pulmonary or cardiovascular disease, or preexisting limitations
in movement can predispose patients to injury. An extensive
review of intraoperative patient positions is beyond the scope of
this chapter; however, the most noteworthy goal with regard to
patient positioning is prevention of pressure ulcers, which have a
surprising incidence of 4.6 to 26. The ASPS has identified six fac-
tors that may prevent the formation of pressure ulcers: preventing
hypotension or local hypoperfusion, padding pressure points to
prevent local pressure in excess of 32 mm Hg, padding pressure
points with layers; reducing operative time to 90 to 120 minutes,
preventing skin moisture buildup (i.e., skin preparation or irriga-
tion) and reducing shear and friction forces during transfer.
4.8.4 Skin Preparation/Scrub
It is clear that antiseptic technique in the operating room has
been one of the single greatest patient safety maneuvers. Skin
Fig. 4.5 Venous thromboembolism (VTE) in single versus combined
procedures (p < 0.05).

 3DWienW SDIeWy in AeVWKeWiF Surgery
47
preparation, hand antisepsis, and other barriers (such as dedi-
cated operating room clothing, masks, and caps) are meant to
minimize surgical site infections as well as to decrease exposure
to the surgeon and operating room staff.
A recent review of hand antisepsis techniques suggested that
rubbing with an alcohol-based solution is more effective than
scrubbing. While scrubbing eliminates transient bacteria, it
removes the stratum corneum and can cause excoriation and
colonization. Like hand scrubs, an ideal skin preparation solution
is broad-spectrum, safe, and easy to use. Commonly used tech-
niques are an iodine soap scrub followed by a paint; alcohol-based
preparations with either iodophor or chlorhexidine; or a simple
soap-and-water preparation. The CDC and the Association of
periOperative Registered 1urses also recommend the avoidance
of shaving operative sites, showering or use of a surgical wash
prior to antiseptic skin preparation, and the need to allow
alcohol-based preparations to dry to prevent operating room fires.
4.8.5 Importance of Normothermia
Hypothermia is defined as a drop in core body temperature
below 36.5 ƒC. Regional and general anesthesia can affect the
body’s ability to regulate core body temperature. Therefore, it is
important that resources be available to assist in heating the cold
patient, such as forced-air warming blankets and fluid warmers
for intravenous and irrigation fluids. Many studies involving
surgical patients have shown that hypothermia correlates with
adverse outcomes, including wound infections and bleeding,
as well as more serious cardiac events. For this reason, ASPS
has developed evidence-based recommendations regarding
hypothermia that include protocols for hypothermia prevention
during general or regional anesthesia. These include actively
prewarming patients, monitoring core body temperature
throughout the procedure, active intraoperative warming with
forced-air heater or resistive-heating blankets, minimizing repo-
sitioning, warm intravenous and irrigation fluids, and aggressive
treatment of postoperative shivering with heat or other pharma-
cologic interventions (Grade B recommendations). In addition,
procedures that do not have all of these strategies available
should be limited to 1 to 2 hours in duration and involve no more
than 20 of the body surface area.
4.8.6 Management of Malignant
Hyperthermia
Malignant hyperthermia is an inherited genetic disorder that
causes a hypermetabolic reaction to potent volatile anesthetic
gases and the depolarizing muscle relaxant succinylcholine.
It is important in the discussion on patient safety because it
represents a preventable and treatable cause of surgical patient
Fig. 4.6 World Health Organization (WHO) Surgical Safety Checklist.

48
I Fundamentals
mortality. Understanding the disease, how to appropriately
identify and screen patients at risk, and how to treat malignant
hyperthermia crisis can save lives.
The incidence of malignant hyperthermia episodes is thought
to be between 1 in 5,000 and 1 in 100,000 anesthetic encounters.
Malignant hyperthermia is inherited in an autosomal dominant
pattern with variable penetrance and has been linked to the
ryanodine receptor type 1 gene, as well as the gene that codes
for the alpha subunit of the dihydropyridine receptor. Because of
this known mode of inheritance, preoperative family history is of
utmost importance. The patient’s medical history intake should
also inquire about other myopathies and inherited muscular
dystrophies that can influence anesthetic choice. Common vola-
tile inhaled anesthetics as well as succinylcholine can trigger the
clinical condition that results from abnormal release of calcium
by muscle cells, ultimately resulting in hyperthermia, hypercap-
nia, hyperphosphatemia, and metabolic acidosis. Patients who
are at risk should be referred to the Malignant Hyperthermia
Association of the United States for further testing, which could
include genetic testing or the gold standard caffeine–halothane
contracture test. The latter involves a muscle biopsy and must be
performed in an accredited facility.
:hile guidelines regarding patient selection and facility
requirements have been established by multiple anesthesia
and surgical societies, both ASAPS and ASPS require that their
members operate only in accredited or licensed facilities for
all procedures that involve more than local anesthesia. Office-
based surgical centers should have reviewed state and national
guidelines and should be prepared with appropriate monitoring
equipment and treatment drugs (which include dantrolene, dex-
trose 50, antiarrhythmics, calcium chloride, sodium bicarbonate,
insulin, furosemide, and adequate ice), as well as an established
malignant hyperthermia emergency protocol.
Nontriggering agents must be used in all susceptible and
suspect patients. However, it should be noted that malignant
hyperthermia can also be triggered by nontriggering agents in
less than 1 of susceptible patients. Treatment protocols have
been created by the Malignant Hyperthermia Association of the
United States, and a hotline is available 24 hours a day, 365 days
a year. Although specific treatment strategies are outside the
scope of this chapter, some salient points will be reviewed. :hile
malignant hyperthermia can be clinically difficult to diagnose,
a herald sign may be a rising end-tidal carbon dioxide level.
Skeletal muscle spasm, trismus, tachycardia, acidosis, hyper-
thermia, and hyperkalemia are other important signs. Treatment
involves discontinuing the offending agent and arranging for
immediate transfer of the patient to the hospital. Administration
of dantrolene sodium stabilizes the ryanodine receptor and is one
of the most critical parts of early resuscitation. It is important
to remember that dantrolene must be reconstituted in injectable
saline prior to administration.
In conclusion, the aesthetic surgery patient undergoing office
procedures with deep sedation or general anesthesia may be at
risk for developing malignant hyperthermia, and patients should
be adequately screened preoperatively. All facilities should be
ready to manage this clinical crisis if encountered. Susceptible
individuals identified preoperatively are not candidates for office-
based surgery.
4.9 Anesthetic Considerations in
Aesthetic Surgery
A complete review of anesthetic considerations in office based
aesthetic surgery is beyond the scope of this chapter. However,
the performance of safe anesthesia (whether that is general,
regional, or local), knowledge regarding common postanesthetic
complications (e.g., postoperative nausea and vomiting), as well
as familiarity with treatment strategies for more serious compli-
cations (i.e., local anesthetic systemic toxicity) are imperative in
any safe and successful aesthetic practice.
4.9.1 Nil per Os
It is common practice to have patients consume nothing by
mouth (nil per os, 1PO) for 8 hours prior to surgery. This recom-
mendation originated from a paper by Mendelson in 1946 that
noted a higher incidence of pulmonary aspiration in obstetric
patients undergoing general anesthesia. This recommendation
was partially revised 50 years later by the American Society of
Anesthesiologists Task Force on Preoperative Fasting, which now
recommends a period of fasting for 8 hours after a meal of fried
or fatty foods but allows a period of 6 hours for milk or a light
meal and 2 hours from clear liquids.
4.9.2 Postoperative Nausea and Vomiting
Postoperative nausea and vomiting (PO1V) are a major concern
for patients and are more pronounced after general anesthesia.
This event can affect upward of 70 of the patient population,
with young women and nonsmokers, or those with a history of
PO1V, at highest risk. 1ot only can PO1V reduce surgical satis-
faction rates, but it also can impact patient safety with regard
to increasing recovery time and possibly causing unplanned
hospital admissions. The use of narcotics and nitrous oxide has
been associated with increased rate of PO1V. Depending on
the situation, many anesthesiologists try to minimize or even
avoid the use of narcotics in favor of improved local anesthesia
and non-narcotic analgesics, such as ketorolac and ketamine.
Other agents can prevent or treat PO1V include ondansetron
(5-hydroxytryptamine
>5-HT@
antagonist),
dexamethasone
(steroid), scopolamine (tropane alkaloid), and metoclopramide
(dopamine and 5-HT antagonist). Combination therapy targets
different pathways to prevent and/or significantly ameliorate
PO1V for many individuals.
4.9.3 Local Anesthetic Systemic Toxicity
The use of local anesthetics is commonplace and usually encour-
aged in aesthetic surgery. Local anesthetics are often mixed
with epinephrine, which allows increased dosing and improved
hemostasis. Aesthetic surgeons must be aware of maximum
local anesthetic dosing, populations at risk (e.g., extremes of
age and pregnancy), as well as rare complications associated
with overdose. Local anesthetic systemic toxicity (LAST) is
a life-threatening complication of local anesthetic overdose
that can cause central nervous system and cardiovascular

 3DWienW SDIeWy in AeVWKeWiF Surgery
49
compromise. The clinical presentation is variable and can occur
hours after injection. Systemic effects are related to sodium
channel blockade and can present with symptoms of perioral
numbness, metallic taste, mental status changes, or seizure.
Cardiovascular symptoms begin with tachycardia and hyperten-
sion, but this ultimately degrades into bradycardia, hypotension,
ventricular arrhythmias, and ultimately asystole with loss of
vascular tone.
Management of LAST is consistent with guidelines and check-
lists published by the American Society of Regional Anesthesia
and Pain Management and includes stopping the injection and
calling for help. The Association of Anaesthetists of Great Britain
and Ireland (AAGBI) have also created safety guidelines that
summarize common recommendations for treatment (Fig. 4.7).
Advanced cardiac life support is instituted, and intravenous lipid
emulsion therapy is initiated. Twenty percent lipid emulsion ther-
apy is administered at a bolus dose by weight and then continued
Fig. 4.7 The Association of Anaesthetists of Great Britain and Ireland (AAGBI) safety guidelines regarding management of severe local anesthetic
toxicity. (Source: The Association of Anaesthetists of Great Britain and Ireland [AAGBI])

50
I Fundamentals
as an infusion. It is believed that the lipid emulsion binds to the
local anesthetic and removes it from affected tissues; however, the
mechanism is likely multifactorial. In addition to lipids, benzodi-
azepines can be used to suppress seizure activity, and airway man-
agement and circulatory support should be primary objectives.
4.10 Concluding Thoughts
The quality of the surgical care that we deliver as aesthetic sur-
geons is inherently intertwined with optimized patient safety.
There are inherent risks to all surgical procedures. Understanding
these risks as they relate to patient characteristics, procedures,
and outcomes, and using this knowledge to optimize the envi-
ronment in which we practice aesthetic surgery, are of utmost
importance.
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51
5 Sedation and Anesthesia for Aesthetic Surgery
Aaron M. Kearney, Sergey Y. Turin, and Sammy Sinno
Abstract
Sedation and anesthesia for aesthetic surgery are crucial topics
for the surgeon to understand in order to optimize the patient
experience. General anesthesia provides total anesthesia and a
lack of awareness, but it incurs higher costs and risks complica-
tions ranging from mild airway irritation to malignant hyper-
thermia. Monitored anesthesia care and lighter levels of sedation
may be used to promote a more rapid recovery but come with
their own risk of aspiration due to an unsecured airway, incom-
plete amnesia and analgesia, and possibly increased difficulty
for the surgeon should the patient be inadequately anesthetized.
Ultimately, the method of anesthesia for a procedure should be
chosen by the patient, surgeon, and anesthesiologist together
and guided by the nature of the procedure, medical comorbid-
ities of the patient if any, and capabilities of the chosen facility.
In this chapter, we discuss principles for ensuring the safety of
patients undergoing aesthetic surgery, choosing an appropriate
anesthetic modality, minimizing the associated risks of anes-
thesia, and managing postoperative complications related to
anesthesia in aesthetic surgery patients.
Keywords
aesthetic surgery, anesthesia, general anesthesia, monitored
anesthesia care, local anesthesia
5.1 Preoperative Evaluation
A simple method for screening patients prior to undergoing
sedation or general anesthesia is the ´Rule of Threes,µ consisting
of the patient’s (1) acute history, (2) chronic history, and (3)
physical examination.
:hen taking a patient’s acute history, the surgeon should
inquire about the patient’s exercise tolerance (e.g., how many
blocks or flights of stairs the patient can walk or climb before
becoming short of breath), history of present illness (e.g., any
major organ system abnormalities, including cardiac, pulmonary,
renal, and neurologic as well as a history of sleep apnea), prior
problems with anesthesia or intubation, and last visit to a primary
care physician. Items in the patient history that suggest difficult
airway anatomy include prior problems with anesthesia; snoring
or sleep apnea; advanced rheumatoid arthritis; and chromosomal
abnormalities. Exercise tolerance correlates with a patient’s car-
diac reserve and is commonly described in metabolic equivalents
(METs). Patients able to perform at least 4 METs without becoming
short of breath have been shown to have improved perioperative
outcomes. Examples of 4 METs include walking 5 city blocks or up
one flight of stairs.
The chronic history should include a patient’s medications,
allergies, social history, and family history of problems with
anesthesia.
The physical exam pertinent to patients undergoing sedation or
anesthesia should include a careful examination of the patient’s
airway, heart, and lungs. The oropharynx is assessed and graded
using the Mallampati classification, which is a predictor of the ease
of orotracheal intubation (Table 5.1). Aside from a high (III or IV)
Mallampati score, exam findings that may suggest a difficult intu-
bation include obesity, a short neck with limited neck extension,
decreased hyoid–mental distance ( 3 cm), cervical spine disease,
syndromic facial features, mouth opening  3 cm, and mandibular
anomalies. These findings, if present, should be noted, as they will
be relevant if endotracheal intubation is required.
After performing a history and physical examination, the
surgeon must determine whether further preoperative testing
is necessary prior to proceeding with the planned surgery. Little
high-level evidence is available to guide preoperative testing,
and current practices are based on guidance from the American
Society of Anesthesiologists (ASA), which is largely based on sur-
veys of anesthesiologists. In general, an electrocardiogram may be
considered in patients with cardiac risk factors, a chest X-ray may
be obtained in patients with pulmonary disease, and a complete
blood count may be obtained in patients with anemia. Coagulation
studies may be obtained in patients with a history of bleeding or
those on anticoagulation. All women of childbearing age should
have a urine pregnancy test prior to undergoing anesthesia.
Patients are commonly stratified according to the ASA classifi-
cation, which provides a global assessment of a patient’s risk of
morbidity (Table 5.2). Patients in low risk categories (ASA I or II)
can be evaluated in the preoperative area on the day of surgery
by the anesthesiologist. For patients with recent hospitalizations,
body mass index (BMI) ! 30, ASA III or greater, anticipated difficult
airway, or cardiopulmonary or other significant comorbidities,
evaluation by an anesthesiologist should be conducted prior to
the day of surgery.
:hile most patients presenting for aesthetic surgery tend to
be in good overall health and present few challenges in terms
of preoperative workup or anesthesia, an important exception
is patients presenting for body contouring after massive weight
loss. Patients who have undergone previous surgery altering their
gastrointestinal (GI) tract are at a high risk of nutritional and vita-
min deficiencies as well as comorbidities concomitant with their
Table 5.1 Mallampati classification
I
Faucial pillars, soft palate, uvula, and tonsillar pillars visualized
II
Faucial pillars, soft palate, and uvula visualized
III
Soft palate and base of uvula visualized
IV
Only soft palate visualized

52
I Fundamentals
obesity. The combination of the risk factors present in this patient
population and the risks of large body contouring surgeries, such
as a higher deep venous thrombosis (DVT) rate, make this by far
the highest-risk cohort in aesthetic surgery. These patients should
undergo a thorough nutrition and medical evaluation prior to sur-
gery and be assessed by the anesthesiologist well ahead of time to
optimize any risk factors.
5.1.1 Preoperative Home Medication
Management
In general, patients should take their home medications the
morning of surgery to maintain steady-state serum levels.
Exceptions to this rule include antiplatelet and anticoagulant
agents, oral hypoglycemic medications, monoamine oxidase
inhibitors (e.g., phenelzine), and herbal supplements.
Antiplatelet agents (e.g., aspirin) should be discontinued 7 days
prior to surgery. Patients on warfarin prior to surgery should be
transitioned to low-molecular-weight heparin by their primary
care physician or other provider who manages their anticoag-
ulation. Patients on novel oral anticoagulants (e.g., apixaban
>Eliquis@, rivaroxaban >Xarelto@) should hold their anticoagulation
for four half-lives prior to surgery (commonly a total of 48 hours).
Patients with bleeding disorders may require replacement of
clotting factors prior to surgery. For a detailed review of bleeding
disorders and thrombophilia, one can refer to the review by Haeck
et al. Herbal supplements should also be discontinued days to
weeks prior to surgery, as these can affect platelet function. It is
prudent to consult with the prescribing physician when cessation
of antiplatelet or anticoagulant agents may be needed for surgery
or if there is any question regarding medications for any cardio-
vascular or pulmonary disease.
5.1.2 Prophylaxis and Anxiolysis
Postoperative Nausea and Vomiting
Postoperative nausea and vomiting (PO1V) is an unpleasant expe-
rience for patients undergoing aesthetic surgery. It also increases
the risk of surgical complications (including wound dehiscence,
hematoma, aspiration, and electrolyte abnormalities).
The three most important risk factors for PO1V are female
sex, nonsmoking status, and a history of motion sickness or prior
PO1V. One simplified risk stratification system for predicting
PO1V utilizes these three factors plus the use of postoperative
opioids. This risk stratification applies to patients undergoing
general anesthesia using inhalational anesthetics. Patients with
no risk factors have a 10 risk for PO1V. Patients with one risk
factor have a 20 risk of PO1V. Each additional risk factor adds a
20 risk of PO1V, for a maximum risk of 80 in patients who have
all four risk factors.
Four proven interventions to reduce the risk of PO1V are
administration of ondansetron >=ofran@, intraoperative dexameth-
asone 4 mg intravenous (IV), droperidol, and total intravenous
anesthesia (due to propofol’s antiemetic activity). Each of these
interventions reduces the risk by approximately one-fourth, and
they work through independent mechanisms. The surgeon may
wish to avoid droperidol because of its relatively short half-life
and controversial effect on the 4–T interval of the cardiac cycle.
Additional antiemetics include anticholinergics (e.g., transdermal
scopolamine), benzamides (e.g., metoclopramide >Reglan@ 25–50
mg), and substance P receptor antagonists (e.g., aprepitant 125 mg
orally >PO@). A suggested algorithm for prevention and treatment
of PO1V is given in Table 5.3.
Table 5.2 American Society of Anesthesiologists (ASA) classification
of patients
ASA class
Medical condition
I
Healthy, no medical conditions
II
Mild systemic disease
III
Severe systemic disease with functional limitation
IV
Severe systemic disease that is a constant threat to life
V
Moribund patient who will not survive without operation
VI
Organ donor
Table 5.3 Prevention and treatment of postoperative nausea and vomiting (PONV)
Condition
7reDWmenW
One risk factor
Dexamethasone 4 mg IV
Two risk factors
Dexamethasone 4 mg IV + ondansetron (Zofran) 4 mg IV
Three risk factors
Dexamethasone 4 mg IV + ondansetron 4 mg IV + total intravenous anesthesia
Four risk factors
dexamethasone 4 mg IV + ondansetron 4 mg IV + total intravenous anesthesia + aprepitant 125 mg PO
Postoperative adjuncts
Ondansetron 4–8 mg every 8 hours IV or ODT
Prochlorperazine (Compazine) 10 mg every 6 hours IV or PO
Metoclopramide (Reglan) 20 mg every 8 hours IV or PO
Trimethobenzamide (Tigan) 300 mg every 6 hours PO or 200 mg every 6 hours IM
Droperidol 1.25 mg IV
Scopolamine transdermal patch every 72 hours
Dexamethasone IV: after induction
Ondansetron IV: 30 min before end of case
Aprepitant PO: given in PACU
Droperidol: second line, Food and Drug Administration (FDA) black box warning for 4–T interval prolongation in cardiac cycle
Abbreviations: IM, intramuscular; IV, intravenous; ODT, orally disintegrating tablet; PO, orally; PACU, postanesthesia care unit.
Adapted from Apfel C. Postoperative and postdischarge nausea and vomiting: risk assessment and treatment strategies. Anesthesiology News 2008(October 29).

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53
Anxiety
Many patients benefit from anxiolysis prior to entering the
operating room. Anxiolytics can improve the anxious patient’s
surgical experience and allow earlier onset of amnesia. Common
medications used for this purpose include diazepam (Valium)
10 to 20 mg PO on the morning of surgery, and midazolam
(Versed) 2 to 4 mg IV prior to entering the operating room.
Hypertension
Patients undergoing procedures for which hypertension is
especially detrimental (e.g., rhytidectomy) may be started on
an antihypertensive preoperatively. The goal of preoperative
prophylaxis is to decrease the risk that surgical stress, local
anesthetic infiltration, and patient awareness will increase blood
pressure. Clonidine is commonly used for this purpose, often
given as 0.1 to 0.2 mg PO the morning of surgery, and it may be
continued twice daily in the perioperative period to reduce the
risk of hematoma due to hypertension (see Chapter 56). 1otably,
postoperative analgesia is another key to avoiding hypertension
due to poorly controlled pain.
5.2 Methods of Anesthesia
The decision of which method of anesthesia to use for a given
procedure depends on the patient’s medical history, inva-
siveness and length of the planned procedure, capabilities of
the facility, and the preferences of the patient, surgeon, and
anesthesiologist.
5.2.1 General Anesthesia
General anesthesia achieves unconsciousness and analgesia
through intravenous and inhaled agents. Respiratory support
is required through either endotracheal intubation (ETT) or
laryngeal mask airway (LMA) with a ventilator. Endotracheal
intubation provides more definitive airway control with less
risk for aspiration, but with a higher risk of postoperative cough,
hoarseness, and sore throat (Table 5.4), with the opposite being
true for LMA. The positioning, type and duration of procedure,
and ease of intubation (should it be needed) are all factors that
are considered in the LMA vs. ETT decision. For each patient, the
airway management method should be discussed and agreed
upon with the anesthesia staff.
5.2.2 Monitored Anesthesia Care
For patients undergoing less invasive procedures, or those in
whom general anesthesia is less desirable, a lighter level of seda-
tion can be provided with monitored anesthesia care (MAC). This
provides a deep level of anesthesia, often using infusions such
as propofol that are carefully titrated by anesthesia personnel to
maintain the patient’s spontaneous respirations.
The advantages of MAC include fewer postoperative side
effects from anesthesia (e.g., hoarseness and cough as intubation
is avoided), more rapid recovery, lower risk of PO1V (if propofol
is used instead of inhalational anesthetics), and lower cost. This
method of anesthesia is ideal for patients undergoing shorter
procedures (less than 3 hours) with good airways and baseline
pulmonary status. The use of MAC provides a comfortable level
of sedation for patients undergoing tumescent liposuction who
wish to avoid general anesthesia. The disadvantages of MAC
include the skill necessary to titrate the sedative medications
carefully, to avoid respiratory depression but provide adequate
sedation, and the lack of definitive airway control should the
patient be unable to maintain spontaneous ventilation. Patients
undergoing MAC should be informed that they may have some
awareness of the procedure and that conversion to general
endotracheal intubation is possible if there is any concern about
maintaining the airway.
5.2.3 Sedation
Procedural sedation can range from minimal sedation, in which
the patient has mild anxiolysis but responds normally to verbal
stimulus, to deep sedation, in which a repeated painful stimulus
is required to elicit a purposeful response (Table 5.5). Moderate,
or conscious, sedation is commonly used for office-based
procedures. During conscious sedation, the patient maintains
spontaneous ventilation and is able to respond purposefully
to verbal and tactile stimuli. Common medication regimens
used for conscious sedation include a combination of a sedative
(typically a benzodiazepine) and an opioid, such as midazolam
and fentanyl. Benzodiazepine hypersensitivity and a history of
acute-angle glaucoma are absolute contraindications to using
midazolam. Common dosing regimens for conscious sedation
are listed in Table 5.6. Conscious sedation is often adminis-
tered without the presence of anesthesia personnel, leaving
the surgeon responsible for ensuring an appropriate level of
sedation. In these cases it is helpful to monitor the patient’s
Table 5.4 Airway management in general anesthesia
Method
AdYDnWDgeV
'iVDdYDnWDgeV
Endotracheal intubation (ETT)
Greatest airway control (e.g., during position changes)
Better for cases in high aspiration risk, maintenance
of airway patency, pulmonary toilet, maintaining
oxygenation
Higher incidence of postoperative cough, hoarseness, sore
throat
Laryngeal mask airway (LMA)
Minimal cardiovascular response during insertion
Fewer postoperative complications
Reusable device (more cost-effective)
Useful in rhinoplasty to act as mechanical barrier for blood
entry down gastrointestinal tract
Does not protect against aspiration, gastroesophageal
reflux, or upper airway bleeding

54
I Fundamentals
pulse oximetry continuously and avoid the use of supplemental
oxygen. The need for supplemental oxygen is an indicator of an
inappropriately deep level of sedation in the absence of anes-
thesia personnel. Anesthesiology guidelines provide guidance
for nonanesthesiologists providing conscious sedation; these
are reviewed in Table 5.7.
5.2.4 Local Anesthesia
Local anesthetics are used as an adjunct in patients under gen-
eral anesthesia, MAC, and conscious sedation or as a stand-alone
analgesic regimen for smaller procedures. Several of the more
commonly used local anesthetics are listed in Table 5.8.
Local Anesthetics
Local anesthetics function by crossing the membrane and
blocking sodium channels to stabilize the membrane of periph-
eral nerve axons, thereby preventing depolarization and nerve
conduction through pain fibers. There are two classes of local
anesthetics: esters and amides. Esters are hydrolyzed by plasma
pseudocholinesterases, have shorter half-lives, and are more
likely than amides to produce an allergic reaction. Amides are
metabolized in the liver and have less potential to cause an
allergic reaction but are more likely to accumulate and cause
systemic toxicity. In patients who have had an allergic reaction
to an ester, an amide may be used for local anesthesia, and vice
versa. A useful memory aid is that the amide local anesthetics
Table 5.5 Types of sedation and anesthesia
7ySe RI DneVWKeViD  VedDWiRn
'eÀniWiRn
General anesthesia
Loss of consciousness, unarousable even to deep painful stimulus
Deep sedation
Responds purposefully to repeated/painful stimulus; respiratory support may be required
Moderate (conscious) sedation
Responds purposefully to verbal or tactile stimulus; spontaneous ventilation maintained
Minimal sedation
Anxiolysis, but responds normally and has a clear airway
Monitored anesthesia care (MAC)
Sedation provided by anesthesiologist, can include conversion to general anesthesia
Adapted from Smith I, Skues M, Philip BK. Ambulatory (Outpatient) Anesthesia. St. Louis, MO: WB Saunders; 2015.
Table 5.6 Conscious sedation protocols
Medication
Class
Dosing
Initiation agents
Diazepam
Benzodiazepine
10–50 mg preoperatively
Midazolam
Benzodiazepine
0.5–1 mg IV every 5–10 minutes
or
0.01 mg/kg preoperatively, then 0.01 mg/kg bolus followed by
continuous infusion at 0.08 mg/kg/h
Ketamine
Dissociative anesthetic
200–750 mcg/kg bolus, followed by 5–20 mcg/kg/min infusion
Fentanyl
Opioid
25–50 mcg every 5–10 min per patient alertness
or
0.7 mcg/kg single dose preop
Reversal agents
Flumazenil
Benzodiazepine antagonist
0.2 mg in incremental doses up to max of 1 mg
Naloxone
Opioid antagonist
0.1–0.2 mg every 2–3 min up to adequate reversal
Adapted from Mustoe TA, Buck DW 2nd, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg
2010;126(4):165e–176e; Cinnella G, Meola S, Portincasa A, et al, Sedation analgesia during office-based plastic surgery procedures: comparison of two opioid
regimens. Plast Reconstr Surg 2007;119(7):2263–2270.
Table 5.7 Recommendations for patient monitoring during conscious sedation
• An additional staff member is recommended, whose primary responsibility is to monitor the level of sedation.
• The patient’s response to verbal commands should be verified every 5 minutes. For patients unable to give a verbal response, a “thumbs up” can
suffice to ensure that the level of sedation is not excessively deep.
• Pulse oximetry, capnography, and heart rate should be monitored continuously. Blood pressure should be measured every 5 minutes, and patients
with significant cardiovascular disease should be monitored with a continuous electrocardiogram.
• It is recommended that someone with the ability to establish airway access and institute positive pressure ventilation be present. It is also
recommended that emergency equipment be available in locations where conscious sedation is provided.
Adapted from Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on
Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental
Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018;128(3):437–479.

 SedDWiRn Dnd AneVWKeViD IRr AeVWKeWiF Surgery
55
have two i’s in the name (e.g., lidocaine is an amide whereas
procaine is an ester).
The pain of injection is the major source of patient discomfort
when local anesthetics are used, and minimizing this pain can
drastically improve the patient experience. Lalonde and col-
leagues have written extensively on this topic; some of the key
points are summarized here:
• Epinephrine:
̑ Use local anesthetics mixed with 1:100,000–1:800,000
epinephrine. Epinephrine provides local vasoconstriction,
which increases the duration of action, reduces bleeding
(and therefore bruising), and allows for higher dosages by
slowing systemic uptake.
• Buffering:
̑ Lidocaine, bupivacaine, and other local anesthetic solutions
are acidic as drawn up from the vial, which contributes to
the discomfort of injection.
̑ To increase patient comfort, buffer the solution 10:1 with
8.4 sodium bicarbonate to reduce the acidity of the injec-
tion solution to a more physiologic pH; e.g., add 1 mL of
bicarbonate buffer to 10 mL of injectable lidocaine.
• Warm the local anesthetic to room temperature using the
palm of your hand.
• Use the smallest-diameter needle feasible (27–30-gauge).
• Switch needles to a fresh needle if one becomes blunt.
• Distract the patient by having them look away. Tactile dis-
traction can be provided by pinching the surrounding skin or
cooling it with ice.
• Preanesthetize the skin using topical anesthetic creams such
as eutectic mixture of local anesthesia (EMLA); a mix of 2.5
prilocaine and 2.5 lidocaine can provide topical anesthesia
prior to injection. 1ote that EMLA requires 90 to 120 minutes
to reach its maximal effect.
• Insert the needle perpendicular to the skin; an oblique angle
will cross more nerve fibers, causing more pain.
• Stabilize the syringe with your nondominant hand to mini-
mize needle movement.
• Inject subdermally, not intradermally.
• Inject a small bleb of local anesthetic immediately after punc-
turing the skin, then pause for a few seconds before slowly
advancing the needle and injecting more.
• Inject into the subcutaneous fat if there is an open wound.
• .eep a wheal of local anesthesia 10 mm ahead of the needle tip
when advancing the needle.
• Only reinsert the needle within 1 cm of the blanched skin
border.
• Have patients score their pain with injection on a scale of
1 to 10, and learn from your own experience.
Local anesthesia can be especially useful for head and neck
procedures. Almost the entirety of the facial skin and a significant
portion of intraoral mucosa can be anesthetized using small
amounts of local anesthetic deposited around the nerves of the
face. Landmarks for local nerve blocks of the face have been well
described by =ide and Swift (Table 5.9).
Tumescence
Tumescence solutions are dilute mixtures of local anesthetics
and epinephrine that reduce pain and significantly reduce
blood loss. They are commonly used during liposuction, which
facilitates the safe removal of large volumes of fat in one setting,
but are also widely used in body contouring, breast surgery, and
other aesthetic procedures. The exact composition may vary, but
typically 2 to 4 mg of epinephrine and 500 to 1,000 mg of lido-
caine are mixed in 1 L of normal saline. Sodium bicarbonate can
be added as 5 mL of 1 mEq/mL sodium bicarbonate for every 1 L
of normal saline to reduce the acidity of the solution. Lidocaine
injected as part of a tumescent solution has been demonstrated
to be safe in doses as high as 35 to 55 mg/kg. Systemic lidocaine
levels peak approximately 12 hours after tumescent injection in
most areas of the body. In the head and neck, plasma levels of
lidocaine peak sooner, approximately 6 hours after infiltration.
For this reason, it is recommended that in cases where both areas
are to be infiltrated with tumescence, the head and neck should
be infiltrated before other areas to reduce the risk of the plasma
Table 5.8 Commonly used local anesthetics (doses based on 70-kg adult)
Name
0D[imum dRVe ZiWKRuW
epinephrine
'urDWiRn ZiWKRuW
epinephrine
0D[imum dRVe ZiWK
epinephrine
'urDWiRn ZiWK eSineSKrine
Esters
Procaine (1–2%)
400 mg
10–30 min
7 mg/kg, max 600 mg
30–40 min
Chloroprocaine
11 mg/kg, max 800 mg
15–30 min
14 mg/kg, max 1,000 mg
Amides
Lidocaine (1–2%)
4.5 mg/kg, max 300 mg
30–60 min
7 mg/kg, max 500 mg
120–360 min
Mepivacaine (1-2%)
300 mg
30–90 min
7 mg/kg, 500 mg
60–120 min
Bupivacaine 0.25%
2.5 mg/kg, max 175 mg
120–140 min
2.5–4 mg/kg, max 225–400
mg
140–180 min
Prilocaine
8 mg/kg, max 500–600 mg
30–90 min
Data from =elman M, Ceradini DJ. Anesthesia in aesthetic surgery. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. New Limited; 2009:27–35; Mustoe TA, Buck DW 2nd, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg
2010;126(4):165e–176e.

56
I Fundamentals
concentration curves being superimposed, raising the risk of
toxicity. To decrease the risk of lidocaine toxicity, the surgeon
has the option of decreasing the amount of tumescent solution
used or using general anesthesia and omitting lidocaine from the
tumescent solution. Bupivacaine should be avoided in tumescent
solutions, as it has a longer half-life and its toxicity is more difficult
to reverse should systemic toxicity occur. For patients intolerant
to lidocaine, prilocaine may be safely substituted when dosed
at 8 to 15 mg/kg. Patients should be observed for 12 hours after
infiltration with prilocaine solutions to monitor for methemo-
globinemia. Signs would include central nervous system abnor-
malities (headache, confusion, seizures), cardiac abnormalities
(chest pain, arrhythmias), and cyanosis. Epinephrine solutions
should be avoided in patients with pheochromocytoma or signif-
icant cardiac or vascular disease. Halothane should be avoided
in patients undergoing tumescent anesthesia, as it increases
the risk of cardiac arrhythmias. Epidural and spinal anesthesia
should also be avoided in patients undergoing tumescent lipo-
suction, as these anesthetic modalities can result in hypotension,
confounding the fluid resuscitation protocols and increasing the
potential for systemic fluid overload postoperatively.
5.2.5 2ffiFe-%DVed AneVWKeViD
Office-based surgery has become an important component of
practice for plastic surgeons. Procedures carried out in the office
have been shown to have lower rates of overall complications,
hematoma, and infection than those carried out at ambulatory
surgical centers and hospitals, with similar rates of venous
thromboembolism. Procedures considered appropriate for office-
based surgical centers include breast augmentation, liposuction,
rhytidectomy, blepharoplasty, rhinoplasty, and laser resurfacing.
Anesthesia administered in offices ranges from local anesthe-
sia alone to general anesthesia. In 2002, the American Society
of Plastic Surgeons Task Force on Patient Safety in Office-Based
Surgery Facilities provided recommendations on the nature of
facilities in which procedures should be performed. Specifically,
it recommended the following:
´Plastic surgery performed under anesthesia, other than minor
local anesthesia and/or minimal oral tranquilization, should be
performed in a surgical facility that meets at least one of the
following criteria:
• Accredited by a national or state-recognized accrediting
agency/organization such as the American Association for
Accreditation of Ambulatory Surgical Facilities (AAAASF),
the Accreditation Association for Ambulatory Health Care
(AAAHC), or the -oint Commission on Accreditation of
Healthcare Organizations (-CAHO).
• Certified to participate in the Medicare program under Title
XVIII
• Licensed by the state in which the facility is locatedµ
Patient selection for office-based surgery is important. State
regulations differ regarding requirements for in-office surgical
facilities. In general, an office-based surgical facility should
have adequate preoperative evaluation, informed consent for
surgery and anesthesia, age- and size-appropriate resuscitation
equipment available, positive pressure ventilation ability with a
well-maintained ventilator, difficult airway algorithm equipment,
defibrillation equipment, oxygen, suction, backup generator, and
intraoperative and postoperative monitoring equipment.
In general, procedures over 6 hours in length or those finishing
after 3 pm should be undertaken in an ambulatory surgery center
or hospital to allow adequate time for recovery. The American
Society of Plastic Surgeons agrees that ASA class I or II patients
are good candidates for office-based surgery using any method of
anesthesia, while ASA III patients should be given no more than
Table 5.9 Sensory blockade of the face
1erYe
/DndmDrN IRr inMeFWiRn
Supraorbital and
supratrochlear (V1)
Palpate supraorbital notch, distract brow laterally, insert needle in middle third of brow pointed toward supraorbital
notch; inject at notch, above notch, and at nasal bone.
Note that periorbital ecchymosis may occur.
External nasal (V1)
Palpate lower ends of nasal bone and inject just below nasal bone, 5–10 mm lateral to midline. Use 1–2 mL per side.
Zygomaticotemporal (V1)
Palpate zygomaticofrontal suture, insert needle 5 mm inferior to the junction of the lateral orbital rim at or below the
lateral canthus. Advance behind lateral orbital rim to 10 mm below the lateral canthus. Inject local while withdrawing
needle.
Zygomaticofacial (V1)
1–2 cm lateral to junction of infraorbital rim and lateral orbital rim.
Palpate junction of infraorbital rim and lateral orbital rim by palpation. Inject 1–2 cm lateral to this point. Use 2 mL.
Infraorbital (V2)
Approach intraorally or percutaneously between the alar base and nasolabial fold, aiming toward medial limbus. Advance
until foramen entered or bony contact made (then “walk up” to foramen). Use 1–2 mL per side.
Mental (V3)
Distract lip over 2nd mandibular premolar, visualize submucosal nerve. Use 1–2 mL. For lower chin, advance
supraperiosteally to lower border of mandible and withdraw while injecting 2–3 mL.
Mandibular division of
trigeminal nerve (V3)
Spinal needle is placed through the sigmoid notch, 1 cm posterior to the pterygoid plate.
Palpate sigmoid notch externally, 2.5 cm anterior to tragus as the patient opens and closes the mouth. Inject small
amount of superficial anesthetic; advance spinal needle perpendicular to face until pterygoid plate is contacted
(approximately 4 cm deep); almost completely withdraw needle, readvance to a point 1 cm posterior to prior point of
contact at the same depth, aspirate, and inject. Use 3–4 mL per side.
Great auricular (C2–3)
6.5 cm inferior to external acoustic meatus over the middle of the sternocleidomastoid; inject on muscle fascia.
Adapted from =ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998;101(3):840–851; =ide BM, Swift R. Addendum to “How to block and tackle
the face.” Plast Reconstr Surg 1998;101(7):2018.

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57
local anesthesia with sedation in an office setting, and ASA IV
patients should be given only local anesthesia with no sedation
in an office-based setting. Additionally, patients with labile or
poorly controlled diabetes mellitus, seizure history, susceptibility
to malignant hyperthermia, morbid obesity, or obstructive sleep
apnea, and those without escorts home, are not candidates for
office-based sedation and should be given no more than local
anesthesia if undergoing in-office procedures.
5.3 Technical Considerations
5.3.1 Thermoregulation
Patients undergoing long procedures involving exposure of
their trunk can be especially prone to intraoperative hypother-
mia. Hypothermia can have deleterious effects on the body,
including increased risk for surgical site infection, impaired
wound healing, altered coagulation, and increased cardiac
stress. Therefore, it is important to take measures intraoper-
atively to maintain normothermia. These can include mini-
mizing exposure of nonsurgical sites, airwarming blankets,
administering warmed intravenous fluids, and increasing the
operating room temperature if necessary. Forced-air warming
is likely not beneficial in procedures that are shorter than 60 to
90 minutes.
5.3.2 Fluid Management
Careful attention should be paid to fluid management, partic-
ularly during large-volume liposuction where fluid shifts can
occur. It is important to maintain euvolemia to maintain the
body’s electrolyte balance and optimize oxygen delivery to the
issues. Fluid resuscitation regimens following large-volume
liposuction are subject to debate; however, it is generally
agreed that some intravenous fluid should be administered
if more than 1 or 2 liters of lipoaspirate are removed in one
setting. Additionally, it is recommended that patients with
greater than 5 L of total aspirate removed be observed in a
facility overnight. It is estimated that up to 70 of tumescent
solution used in liposuction becomes intravascular and is not
aspirated. In standard liposuction cases, patients should be
administered maintenance intravenous fluids while under
anesthesia, and it should be expected that 70 of the tumes-
cent will become intravascular. In large-volume liposuction
cases with over 5 L of aspirate, 0.25 mL of intravenous fluid for
every 1 mL of aspirate should be infused as a bolus at the end
of the case.
5.3.3 Patient Positioning
Careful attention must be paid to adequate positioning of the
patient so as to avoid pressure-induced skin injury and neu-
ropathy. Particular points of consideration include the cubital
tunnel, axilla (especially in lateral position), and heels. Correct
positioning is a patient safety issue, and justification cannot be
made for neglecting it: nerve injury is only second to death in
causes of settled liability claims related to anesthesia.
5.4 Postoperative Management
There are three phases of recovery from anesthesia. Phase 1
starts in the operating room when the anesthetic agents are
stopped and continues in the postanesthesia care unit (PACU).
Motor function, spontaneous ventilation, and airway protective
reflexes return, and vital signs are closely monitored.
Phase 2 typically takes place in the PACU or secondary recovery
area, where the patient’s vital signs can still be monitored and the
patient is observed for pain, nausea, vomiting, and bleeding. The
patient’s ability to ambulate is assessed, and he or she is evaluated
for discharge home. This typically occurs during the 1 to 2 hours
following surgery. Ability to tolerate oral intake is not a typical
discharge requirement, and it has not been shown to correlate
with PO1V.
During phase 3, the patient’s body returns to its baseline phys-
iology. This portion of recovery typically occurs at the patient’s
home following ambulatory surgery.
5.4.1 Complications
Postoperative Nausea and Vomiting
PO1V is the most common complication following anesthesia. It
occurs in 20 to 30 of patients in the general population and in
up to 70 to 80 of high-risk individuals. Eighty percent of PO1V
occurs within 48 hours from surgery, but 65 of these patients do
not have symptoms until leaving the surgery facility. The use of
volatile anesthetics, nitrous oxide, and intraoperative and post-
operative opioids, as well as longer surgical duration, increase
the risk of PO1V. In plastic surgery, PO1V is more common in
patients undergoing breast augmentation.
The best way to avoid PO1V is to administer prophylaxis to
patients at high risk. This can include anticholinergics, serotonin
antagonists, and steroids, as mentioned previously. Additionally,
an anesthesia plan can be tailored to avoid agents more likely to
provoke PO1V, such as inhalational agents.
Ondansetron, scopolamine, and prochlorperazine are the main-
stays of treatment for PO1V. These can be administered in the
recovery unit. For patients who are otherwise meeting criteria for
discharge except for persistent PO1V, ondansetron oral dissolving
tablets can be prescribed for continued PO1V control at home.
Hoarseness, Cough (Airway Irritation)
Hoarseness and cough are more likely to occur following endo-
tracheal intubation and occur due to airway irritation. These
symptoms almost always resolve spontaneously within hours
after surgery. Topical anesthetic lozenges can be used for symp-
tomatic relief.
Local Anesthetic Systemic Toxicity
Local anesthetic systemic toxicity (LAST) is a rare but potentially
fatal complication of local anesthesia. It occurs when plasma
levels of local anesthetic exceed the toxicity threshold and cause
physiologic derangement. Central nervous system symptoms
precede signs of cardiac dysfunction. The earliest symptoms

58
I Fundamentals
include tinnitus, perioral paresthesias, and restlessness. This can
be followed by seizures, respiratory arrest, and cardiac depres-
sion. Treatment is instituted using basic life support principles
(the ABCs: airway, breathing, circulation) and advanced cardiac
life support as necessary. Additionally, intravenous lipid emul-
sion therapy is begun as soon as feasible. Any frequent user of
local anesthetics should be familiar with the treatment of LAST.
For reference, the user is referred to the free LipidRescue algo-
rithm, available from the American Society for Aesthetic Plastic
Surgery.
Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare, life-threatening com-
plication of general anesthesia that occurs following the admin-
istration of succinylcholine or volatile agents. Signs include
rapid-onset tachycardia, acidosis, hypercarbia, muscle rigidity,
and fever. MH may be difficult to diagnose intraoperatively, as
there are several possible causes for this clinical scenario. Two
particular signs that should alert the surgeon to the diagnosis of
MH are a rise in end-tidal CO2 associated with masseter spasm or
trismus. The treatment for MH is cessation of offending agents,
administration of dantrolene (a muscle relaxant), cooling as
necessary, and frequent vital sign and electrolyte/metabolite
monitoring. Every surgical facility using succinylcholine or
volatile agents should have dantrolene available for this reason.
MH is inherited in an autosomal dominant fashion with variable
penetrance, with most cases linked to a mutation in the RYR1
gene. Anesthetics appropriate for patients susceptible to MH
include propofol, opiates, and nondepolarizing muscle relaxants.
Patients with muscle disorders or paraplegia should not be given
succinylcholine, either, as this can trigger a life-threatening
rhabdomyolysis and hyperkalemia similar to MH. Procedures
with sedation in patients susceptible to MH should be under-
taken in an accredited ambulatory surgery center or hospital.
Patients with suspected susceptibility to MH can be referred to
the Malignant Hyperthermia Association of the United States for
testing, which is undertaken through a surgical muscle biopsy
and caffeine-halothane contracture test (gold standard) or RYR1
mutation screening (less sensitive).
Benzodiazepine or Opioid Overdose
Any procedure involving sedation requires a careful titration
of medications to ensure adequate analgesia and anxiolysis
while permitting adequate spontaneous respiration. During
the administration of sedation, it is important to monitor the
patient’s level of sedation periodically (e.g., every 5 minutes)
by eliciting a response to verbal stimulus or, if the patient is
unable to talk, eliciting a motor response such as a ´thumbs up.µ
Excess doses of benzodiazepines or opioids lead to respiratory
depression with hypoventilation or even respiratory arrest. In
this emergency it is important to provide artificial respiration
(i.e., bag-valve mask) and immediately institute reversal of the
relevant sedative agents. The American Society for Aesthetic
Plastic Surgery has published a quick-reference guide to the
dosing of flumazenil and naloxone for benzodiazepine and opioid
reversal, respectively.
5.5 Concluding Thoughts
Effective anesthesia allows patients to undergo aesthetic surgery
safely so as to restore or improve their body image. Modern-day
anesthesia services are overall very safe, with a low risk profile,
in part due to thoughtful preoperative evaluations by surgeons
and anesthesiologists. A variety of anesthetic modalities exist,
ranging from general anesthesia to monitored anesthesia care,
conscious sedation, and local anesthesia alone. This chapter
provides a framework to assist the surgeon in choosing an
appropriate anesthetic plan in concert with an anesthesiologist,
in managing the patient’s perioperative symptoms that may
be related to anesthetic medications, and in being cognizant of
potential adverse effects related to anesthesia. It is our hope that
this will assist the reader in providing an optimal experience for
patients undergoing aesthetic surgery.
Clinical Caveats
• ASA classification is a global assessment that classifies
patients according to medical fitness.
• In general, patients should take their home medications the
morning of surgery to maintain steady-state levels.
• Risk factors for PONV include female, nonsmoker, past history
of PONV, history of motion sickness, young age, migraine
history.
• Other than procedures performed using local and mild oral
tranquilization, surgery should be carried out in an accredited
facility.
• Conscious sedation commonly uses midazolam for sedation
and fentanyl for analgesia.
• Amides contain the letter I in the prefix of the generic name.
• To avoid pain, insert needle perpendicular to skin, use small
needles (27- or 30-gauge), and inject and advance slowly.
Suggested Reading
>1@ American Society for Aesthetic Plastic Surgery. LipidRescueŒ. 2019. https://

Accessed September 22, 2019
>2@ Apfel C. Postoperative and postdischarge nausea and vomiting: risk assessment
and treatment strategies. Anesthesiol News 2008(October 29).
thesiologynews.com/Review-Articles/Article/10-08/Postoperative-and-Postdis-
charge-1ausea-and-Vomiting-Risk-Assessment-and-Treatment-Strategies/11751
Accessed September 22, 2019
>3@ Cinnella G, Meola S, Portincasa A, et al. Sedation analgesia during office-based
plastic surgery procedures: comparison of two opioid regimens. Plast Reconstr
Surg 2007;119(7):2263–2270
>4@ Haeck, P. C., et al. (2009). ´Evidence-Based Patient Safety Advisory: Blood Dyscra-
sias.µ Plastic and Reconstructive Surgery 124(4S):82S-95S
>5@ Mustoe TA, Buck D: 2nd, Lalonde DH. The safe management of anesthesia,
sedation, and pain in plastic surgery. Plast Reconstr Surg 2010;126(4):165e–176e
>6@ Practice guidelines for moderate procedural sedation and analgesia 2018: A
report by the American Society of Anesthesiologists Task Force on Moderate
Procedural Sedation and Analgesia, the American Association of Oral and Maxil-
lofacial Surgeons, American College of Radiology, American Dental Association,
American Society of Dentist Anesthesiologists, and Society of Interventional
Radiology. Anesthesiology 2018;128(3):437–479
>7@ Rubin -P, Xie =, Davidson C, Rosow CE, Chang <, May -: -r. Rapid absorption
of tumescent lidocaine above the clavicles: a prospective clinical study. Plast
Reconstr Surg 2005;115(6):1744–1751

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59
>8@ Scarborough DA, Herron -B, .han A, Bisaccia E. Experience with more than 5,000
cases in which monitored anesthesia care was used for liposuction surgery.
Aesthetic Plast Surg 2003;27(6):474–480
>9@ Shafer DM, Opperman S. Postoperative Nausea and Vomiting. 1ew Elsevier Limited; 2009
>10@ Shermak MA. Pearls and perils of caring for the postbariatric body contouring
patient. Plast Reconstr Surg 2012;130(4):585e–596e
>11@ Smith I, Skues M, Philip B.. Ambulatory (Outpatient) Anesthesia. St. Louis, MO:
:B Saunders; 2015
>12@ Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia
injection. Plast Reconstr Surg 2013;132(3):675–684
>13@ =elman M, Ceradini D-. Anesthesia in aesthetic surgery. In: Aston S-, Steinbrech
DS, :alden -L, eds. Aesthetic Plastic Surgery. Elsevier Limited; 2009:27–35
>14@ =hou -, et al. Malignant Hyperthermia and Muscle-Related Disorders. St. Louis,
MO: :B Saunders; 2015:1
>15@ =ide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg
1998;101(3):840–851
>16@ =ide BM, Swift R. Addendum to ´How to block and tackle the face.µ Plast Reconstr
Surg 1998;101(7):2018

(Trang không có chữ)

Part II
Business Basics
II

(Trang không có chữ)

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63
6 :Ky 2̵er AeVWKeWiF 0ediFine in Dn AeVWKeWiF SurgiFDO
Practice?
Ali A. 4ureshi, Renato Saltz, and W. Grant Stevens
Abstract
Aesthetic surgeons may wonder, ´:hy offer aesthetic medicine
in an aesthetic surgical practice"µ The answered is based on
the ´Five Psµ of aesthetic medicine: patient acquisition, patient
retention, patient optimization, patient education, and patient
conversion. Aesthetic medicine accounted for over 2 billion in
2017 and continues to grow with newer demographics such as
men and younger patients seeking services. The explosion in
new nonsurgical technologies and treatments, combined with
patients’ demands for quick, effective solutions to look refreshed,
has compelled plastic surgeons to incorporate aesthetic medi-
cine. :e will explore in this chapter how aesthetic medicine is
a core part of aesthetic plastic surgery, can help grow a prac-
tice, and above all, can lead to better results for our patients.
Specifically we look at the ´747µ effect and how to build a practice
with ´patients for life.µ 1ew paradigm shifts, such as outcome
optimization with pre- and postsurgical skin treatments and the
subscription model of aesthetic services, are also explored.
Keywords
aesthetic medicine, nonsurgical, noninvasive, cryolipolysis,
injectables, lasers, facials, skin treatment, subscription model,
patient optimization, practice management
6.1 Introduction
Aesthetic surgeons have long debated the value of offering com-
prehensive aesthetic medical services as a part of their surgical
practices. 1aysayers question the value of nonsurgical services to
their practice and patients. 1onsurgical aesthetic services may be
viewed as a ´disruptive technology,µ forcing aesthetic surgeons to
reassess and re-evaluate how to incorporate these services into
their surgical practices. Competition from nonplastic surgeons
and industrywide competition have also been disruptive forces,
leading to change and blurring the divisions between cosmetic
procedures and aesthetic surgery. Our personal experience and a
growing body of evidence demonstrate a number of compelling
reasons it would behoove aesthetic plastic surgeons to offer these
services. These ´five Ps of aesthetic medicineµ are all centered
on patient care (Fig. 6.1): patient acquisition, patient retention,
patient optimization, patient education, and patient conversion.
The globalization of beauty, changing demographics and cul-
tural preferences, and advances in technology are shaping and
transforming the aesthetic marketplace. Cosmetic medicine offers
exciting options for practices to grow and expand. The growth in
nonsurgical and aesthetic medical consumption has been expo-
nential; it accounted for nearly 2 billion in 2017, according to the
American Society for Aesthetic Plastic Surgery (ASAPS) Cosmetic
Surgery Data Bank. -ust from 2012 to 2017, injectables saw a 40
increase while skin rejuvenation saw a 30 increase in utilization.
Even more impressive, nonsurgical fat reduction increased over
200 in the same time period. More than ever, men have been
seeking nonsurgical aesthetic treatments, accounting for 10 of
services in 2017. The top five nonsurgical procedures in 2017
were neurotoxin, filler, nonsurgical fat reduction, hair removal,
and chemical peel. Areas with major growth have included
microablative skin resurfacing and nonsurgical skin tightening
procedures. The International Society of Aesthetic Plastic Surgery
(ISAPS) has also seen exponential growth in nonsurgical proce-
dures, demonstrating that the demand for such services is truly a
global phenomenon.
These numbers demonstrate not only the magnitude of demand,
but also the distribution and type of nonsurgical aesthetic ser-
vices patients seek. Patients continue to seek quick and effective
solutions in order to look young and refreshed. The services they
seek range from laser therapies to cryolipolysis to ultrasound skin
tightening to peels and facials. The breadth of aesthetic services
cannot be underestimated. It is this diversity of services that can
enable a surgical practice to incorporate nonsurgical aesthetic
services selectively to complement the surgeries they offer or spe-
cialize in. This will, in turn, appeal to a broader range of patients
over a long term, leading to ´patients for life.µ
A landmark study in 2007 from the Cosmetic Medicine Task
Force of the ASAPS and American Society of Plastic Surgery
(ASPS) highlighted prevailing perceptions and trends in cosmetic
medicine. The task force was established to address the disruption
caused by noncore providers entering the aesthetic field, the
Fig. 6.1 The five Ps of aesthetic medicine.

64
II Business Basics
growing popularity of nonsurgical procedures, and emergence of
medical-grade spas. The study found that the public considered
injectables low-risk procedures and that these patients were more
price-sensitive and likely to seek providers of any specialty with
a lower price point. Patients were found to be just as likely to see
noncore providers as to see plastic surgeons for these services. The
most significant finding was what is now called the ´747 effect.µ
:hen surveyed women were asked whom they would choose
to perform their cosmetic surgery, 93 would choose a plastic
surgeon and 7 would choose a noncore doctor or dermatologist.
Only 25 would choose a plastic surgeon to perform a minimally
invasive procedure (laser, injectables, peels, microdermabrasion,
etc.)³and of patients who had a positive experience with a non-
invasive procedure with a nonplastic surgeon (either a dermatol-
ogist or noncore physician), 47 would stay with the nonplastic
surgeon for a cosmetic surgery as well. Similar surveys performed
by the Sociedade Brasileira de Cirurgia Plastica (SBCP) in Brazil,
the second-largest cosmetic surgery market in the world, had very
similar findings.
The Cosmetic Medicine Task Force conclusion was obvious:
demand for our surgical procedures could be in jeopardy if aes-
thetic plastic surgeons do not capture new patients early in their
experiences with aesthetic medicine. Indeed, the impact of such
sentiments could drastically affect the flow of patients into the
operating rooms. In order to preserve aesthetic plastic surgery,
aesthetic surgeons must be willing to incorporate ´disruptive
technologiesµ such as nonsurgical procedures and aesthetic
medicine into their practices. Aesthetic medicine and nonsurgical
procedures need to be incorporated into the training of residents
and fellows in plastic surgery and our daily practices, or plastic
surgeons may not remain relevant as the specialty of aesthetics.
6.2 Patient Acquisition
Cryolipolysis is an ideal example of how a nonsurgical aesthetic
service leads to patient acquisition. :ith nonsurgical fat reduc-
tion seeing one of the largest periods of growth since 2012,
this service offers a unique opportunity for practice growth.
Stevens et al describe their clinical and business experience with
cryolipolysis in 2013. Of over 500 new patients to the practice,
66 came specifically seeking cryolipolysis with CoolSculpting
(Allergan, Dublin, Ireland), and 62 had never had an aesthetic
procedure. This provided an opportunity to introduce patients
to other offerings within the practice: injectables, skin care, laser
hair removal, and even surgical procedures performed by the
aesthetic plastic surgeons in the practice. Forty percent of these
patients actually came back to the practice to avail themselves of
other aesthetic treatments. These same patients had previously
never had aesthetic surgery at the practice, let alone a nonsur-
gical treatment. Interestingly, 95 of patients had never had an
injectable treatment, with either neurotoxin or soft tissue filler,
and the practice found that the service most commonly used by
returning cryolipolysis patients was for injectables.
The study also found that offering nonsurgical procedures
expanded the male demographics of the practice. After a targeted
marketing campaign specifically tailored for men, nearly 42 of
all cryolipolysis clients were men. This demonstrates that non-
surgical aesthetic services bring patients into a surgical practice
that they may have otherwise never considered. This can be a very
powerful tool for new practices seeking to establish themselves or
mature practices that seek to expand their demographic, as the
case may be with male clientele.
In a study by .urkjian et al examining the impact of economic
factors on facial aesthetic surgery, an overwhelming majority of
patients preferred treatments that have a long-lasting effect over
those with shorter duration. Only physician’s training and exper-
tise with the treatment superseded this as a treatment decision
driver. Further, over half of respondents said that their decision to
have an aesthetic facial treatment was affected by the economy. It
is important for aesthetic practices to offer diverse services with
a range of price points for new patient acquisition. The study also
suggests that well-trained aesthetic surgeons should consider
offering nonsurgical treatments, as one of the most important
factors for patients choosing to have a treatment is the physician’s
training and background. Plastic surgeons have a unique opportu-
nity to offer these services.
A new paradigm shift in nonsurgical aesthetic services is cur-
rently under way, with a subscription aesthetic services model
that also helps with patient acquisition. This model has been suc-
cessful in other industries. Apple (Cupertino, CA) saw a doubling
in sales of its iPhones when it started a monthly payment service;
there is increasing momentum for a similar subscription model
in aesthetics. Previous studies have demonstrated that cost can
be a barrier when drawing a wider audience into aesthetics, and
this model may be an affordable option that will increase patient
acquisition.
6.3 Patient Retention
Given that it costs five times as much to acquire a new customer
as to retain an existing one, building loyalty is paramount to any
business. Creating a loyal aesthetics customer, however, is not an
easy task, as many patients prefer to shop around for hot deals
rather than return to the same practice for repeat treatments.
The growth in nonsurgical procedures and the aesthetic med-
icine industry might not translate to increases in revenue for
individual practices that are unable to retain their patients. It is
not that the patients are no longer seeking treatment³it is that
they are going elsewhere.
As many other physicians and nonphysicians increasingly
become involved in aesthetic medicine, it is important that aes-
thetic surgical patients be retained in the practice. As previously
mentioned, the 2007 seminal study by the Cosmetic Medicine
Task Force found that 47 of patients would be willing to return
to someone other than a plastic surgeon for an invasive aesthetic
procedure based on a prior positive noninvasive treatment with
that provider. This could bode poorly for aesthetic surgeons as we
try to maintain high quality and excellent outcomes in aesthetic
surgery. Maintaining patients in a practice will lead to multiple
encounters and potential procedures over the course of their
lifetime. For example, we found with cryolipolysis that 40 of new
patients who were seen remained in the practice for up to 4 years
after their treatments, which was the longest follow-up available
from the study at the time.
The subscription model of aesthetic services is a unique way to
deliver ongoing aesthetic services to patients and retain patients.

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Instead of patients’ waiting for the effects of their neurotoxin or
filler to wear out before seeking treatment again, subscription
services enable patients to maintain their results. In our practice,
prior to implementing a subscription model, neurotoxin patients
were coming, on average, 2.1 times per year, waiting for the effects
of the neurotoxin to diminish and then often having difficulty
making time for themselves to come in for a treatment. Since we
implemented a subscription model for aesthetic services, patients
now maintain their neurotoxin results and come in more often, on
average 3.7 times per year. This has dramatically improved patient
retention, as these patients are no longer seeking treatments
elsewhere or seeking a lower price point each time they need a
treatment.
6.4 Patient Optimization
Aesthetic surgeons pride themselves in their surgical outcomes
and want their patients to look as good as they can. Presurgical
treatments with skin care, facials, and proper cosmeceuticals
can prepare a patient for an optimal surgical outcome particular
in facial aesthetic surgery. Interestingly, the concept of patient
optimization for improved surgical outcomes is not a new con-
cept. The use of tretinoin or hydroquinone prior to laser therapy,
or weight loss before an abdominoplasty, are just a few examples
of plastic surgery dogma in patient optimization. The use of
noninvasive devices to enhance a facial surgical outcome is an
extension of that same philosophy.
In our practice, the use of noninvasive aesthetic services to
enhance surgical outcomes is called ´the icing on the cake.µ
This includes laser resurfacing, microneedling, nonsurgical skin
tightening, fillers, neuromodulators, skin care, facials and bio-
logically-active cosmeceuticals. Aesthetic medical services and
products optimize the appearance of our surgical patients, and
this optimization leads to higher patient satisfaction as well as
practice growth.
Increasingly, pretreatment and priming of the skin before
surgery and noninvasive treatments with medical-grade skin care
products is taking place. The thought is that, just as one would
perform surgical dpbridement before doing a flap, medical-grade
skin products cleanse the skin and prepare it for undergoing the
knife and being manipulated. For example, skin care products can
be used a few weeks in advance of a facelift so that the skin is
´primedµ and ´ready to goµ for the healing process. :e anticipate
this to be a rapidly growing trend and could be the next paradigm
shift in patient optimization. It is a sort of ´refining the sugarµ
before baking the cake and icing it.
Patient optimization with noninvasive technologies is not
limited to facial aesthetic surgery. They have a role even in breast
and body surgery with scar management, for example. Different
devices that focus on lymphatic massage can also be adjuncts for
patients who have had liposuction or other body contouring sur-
geries. Appropriately selected nonsurgical vaginal rejuvenation
devices can also be used as adjunct procedures when treating
labiaplasty patients with sexual dysfunction or distress, which
can be prevalent in plastic surgery patients. The subscription
model for aesthetic services has improved patient optimization,
with patients visiting the practice more often, utilizing more
products with less time between visits and better results.
:hen the philosophy of the practice is deliver the optimal
outcome for the patient, the surgeon and the practice must use
more than just the scalpel; adjunct technologies must be used to
deliver that result and complement what happens in the operat-
ing room.
6.5 Patient Education
:hen patients are treated with nonsurgical modalities, they are
often in the office for extended periods of time, which can be a
couple of hours. This time may include preprocedure numbing or
postprocedure massage, depending on the nature of the treat-
ment. Unlike in the operating room under a general anesthetic,
patients using nonsurgical aesthetic services are awake. This
means there is an opportunity to engage patients and educate
them about aesthetic services that the practice offers.
This one-on-one time between staff and patients is invaluable.
It is a true teaching moment and can be a costly missed opportu-
nity for patient and surgeon. Patients can be exposed to videos
or before-and-after photo books of surgical and nonsurgical
procedures. These visual cues often lead to questions that staff
can answer and, in our experience, has been a real opportunity to
dispel myths about surgery and outcomes. Many of our patients
who receive nonsurgical services ultimately go on to become
surgical patients because they have learned to trust the surgeon
and the practice and feel empowered with the aesthetic medicine
education they got in the office.
Simple interventions such as surveys can actually help both
retain and educate patients about nonsurgical procedures. In a
pilot study performed in the 1ortheast, 17 practices administered
a Cosmetic Interest 4uestionnaire (CI4), which simply asked
patients whether they were interested in a list of possible nonsur-
gical treatments. Staff would then follow through with any areas
that patients said they were interested in and provide information
such as before and after photographs. Patients were educated
and questions about procedures were addressed. A total of 2,673
surveys were administered, and almost 60 (n 1,586) had an
inquiry. This led to almost 20 new cosmetic appointments for
nonsurgical procedures.
6.6 Patient Conversion
It is this conversion of a nonsurgical patient to a surgical patient
that is the lifeblood of an aesthetic surgical practice. A recent
study performed confirmed that there was a 40 retention in
nonsurgical patients, and the revenue stream was 400 greater
than the original nonsurgical revenue stream. Most of this
revenue was from surgical procedures. As aesthetic surgeons,
our goals are happy patients and also doing more surgery. The
conversion to surgical patients is key and follows the educational
process.
A single-surgeon experience reported by Richards et al with
injectables and facial aesthetic surgery identified over 15 con-
version of aesthetic-nawve new patients, who came to a practice
for injectables and converted to surgical patients at an average
of 19 months. On average, patients had three injectable sessions
before converting to a surgical procedure at this practice, which
included facelift, upper blepharoplasties, and brow lifts. Other

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II Business Basics
studies have also shown that patients who ultimately went on to
have a facelift had previously undergone multiple noninvasive
aesthetic procedures.
6.7 Concluding Thoughts
For aesthetic plastic surgeons to continue providing high-vol-
ume and high-quality surgical care, practices must be willing
to incorporate aesthetic medicine. The diversity of treatments,
procedures, and price points enables practices to tailor a set of
services to meet their clientele. :hether with the scalpel or with
the needle, the goal is to achieve the best result possible for each
patient and help patients achieve their aesthetic ideals.
Suggested Reading
>1@ D’Amico RA, Saltz R, Rohrich R-, et al. Risks and opportunities for plastic surgeons
in a widening cosmetic medicine market: future demand, consumer preferences,
and trends in practitioners’ services. Plast Reconstr Surg 2008;121(5):1787–1792
doi: 10.1097/PRS.0b013e31816c3c49
>2@ .urkjian T-, .enkel -M, Sykes -M, Duffy SC. Impact of the current econ-
omy on facial aesthetic surgery. Aesthet Surg J 2011;31(7):770–774 doi:
10.1177/1090820X11417124
>3@ Saltz R. Cosmetic Medicine and Aesthetic Surgery: Strategies for Success. St. Louis,
MO: 4uality Medical Publishing; 2009
>4@ Stevens :G, Pietrzak L., Spring MA. Broad overview of a clinical and commer-
cial experience with CoolSculpting. Aesthet Surg J 2013;33(6):835–846 doi:
10.1177/1090820X13494757
>5@ Richards BG, Schleicher :F, D’Souza GF, Isakov R, =ins -E. The role of injectables
in aesthetic surgery: financial implications. Aesthet Surg J 2017;37(9):1039–1043
doi: 10.1093/asj/sjx136

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7 Optimal Correction and Patient Retention: A Personal
Philosophical and Practical Approach to Your Nonsurgical
Practice
A. Jay Burns
Abstract
Historically, surgical practices including plastic surgery focused on
optimizing clinical outcomes. Talking about optimizing the busi-
ness side and profits were taboo. Today, things are changing rap-
idly for many, if not most, plastic surgeons as they look for ways to
both optimize profits and enhance secondary, passive income. This
chapter directly addresses ways to achieve these financial goals
while, unflinchingly and appropriately, maintaining a priority on
optimizing patient outcomes and satisfaction. A comprehensive
patient consultation focuses on ´full correctionµ in scope. 1ot only
is the surgery discussed, but a long-term, comprehensive surgical
and nonsurgical plan to ´full correctionµ is also discussed in detail.
It is incumbent on the surgeon to understand all of the nonsurgical
options and to be able to provide them to surgical patients with
expertise and confidence. These options are highlighted.
Optimally, the patient leaves the office with a comprehensive
aesthetic plan. However, obstacles the patient must overcome
in remaining loyal to such a plan are the financial costs and dis-
tractions of a busy lifestyle. Such obstacles and the methods to
overcome them are discussed. Specifically, the author will focus
heavily on the role of aesthetic subscriptions as a model to opti-
mize patient loyalty and retention and to overcome the hurdles
discussed. Data will be given proving the validity of this approach
in many practices as well as his own.
Keywords
full correction, comprehensive long term aesthetic plan, sub-
scription economy, aesthetic subscriptions, patient loyalty,
patient retention
7.1 Introduction
As a physician who identifies first and foremost as a surgeon,
I have spent a significant portion of my career in a parallel
universe of nonsurgical approaches to aesthetic concerns. This
chapter would have never been included in a reputable textbook
when I began my career over 30 years ago, because nonsurgical
techniques were ignored at best and deemed disreputable at
worst. Thankfully, we have come a long way since then, and most
successful aesthetic surgeons now understand the value of their
nonsurgical practice.
I feel honored to contribute to such a prestigious textbook and
take the responsibility very seriously. However, I must make it
clear this chapter is a wholly personal perspective. Such personal
bias will differ from others’ reasonable opinions, but there are no
substantial studies to prove a ´best approach,µ so I simply present
mine, which, without argument, has proven both beneficial to my
patients and successful for my business.
My opinions are based on general and plastic surgery training,
as well as over 30 years of running a surgical and nonsurgical
practice. During this time, I have also had an academic career in a
teaching institution and been fortunate to be involved in research,
Food and Drug Administration (FDA) studies, and many scientific
advisory boards, which have helped introduce innovative technol-
ogies such as lasers, radiofrequency, ultrasound, and cryolipolysis
to market. Therefore, while certain opinions on management and
business decisions will be personal, many more will be based on
scientific research and data.
I have a gift from one of my best friends from medical school,
which I often ponder over. It is a framed quotation from Sir
:illiam Osler that reads:
´ing which exacts at you at every turn self-sacrifice, devotion, love,
and tenderness to your fellow man. Once you get down to a purely
business level, your influence is gone and the true light of your life
is dimmed. of charity that raises you far above the petty jealousies of life.µ
I feel strongly that, as physicians, our calling is a privilege and a
responsibility. I am not here to place a relative moral value on aes-
thetic plastic surgery, but if our focus is to put our patients’ wishes
above our own, then I believe we can abide by Osler’s famous
challenge, and if our surgery practice and business is successful and
efficient, it is no sin. :hether we are treating patients for coronary
blockage, cancer, psychiatric illness, or the visible signs of aging,
I believe we can deliver care with the patients’ best interests at
heart³optimizing quality and results in the safest manner possible.
I truly believe that both objectives³excellent patient care and a
successful business³can be achieved with integrity, and the aim
of this chapter is to make that point to you and hopefully help
you achieve those goals. By putting patients first and offering a
quality, comprehensive program with long-term optimal results,
I know that every aesthetic physician can achieve happy patients
and a thriving business.
7.2 Consult with a Purpose
Ask yourself this: If you provided your patients with the best
experience and quality results, every time, why would they
even think about going anywhere else" I believe that, as plastic
surgeons, we are uniquely trained to offer a full complement of
treatments to aesthetic patients. Therefore, we should always
provide, in addition to the best surgical solutions, the most tech-
nically advanced nonsurgical services and treatments as well as
scientifically proven skin care and sun protection.

68
II Business Basics
This all starts with a comprehensive consultation . . . with a
purpose.
My initial consult always addresses every available option to
the patient, regardless of the patient’s primary focus. The purpose
for this is to optimize my chances of retaining a satisfied patient
for life. I listen carefully to their desires, biases, fears, and expecta-
tions, and if their expectations are reasonable, I move forward to
create a ´win–winµ for us both. And, by the way, if their expecta-
tions are anything short of reasonable, I have found that it is best
to avoid a doctor–patient relationship of any kind.
:e all understand that patients are most satisfied when they
are fully corrected. The key, however, is to educate them on how to
achieve this reasonably and logically. They must understand we are
talking about ´optimalµ results, while never implying perfection. I find
that an educational approach always leads to the most satisfied and
loyal patients, and I go about it by explaining facial aging in four ways:
1. Gravity: The results of gravity are manifested by certain physical
findings, including neck laxity, jowls, marionette lines, nasolabial
folds, and droopy eyebrows. I realize there are varying opinions
on the value of addressing only the skin, versus the fascial lay-
ers when discussing the results of gravity, but I like to inform the
patient that skin is an elastic layer, which, when young and tight,
shows benefits, but over time will relax and reveal signs of aging.
Gravity is also a major player when it comes to laxity of the platys-
ma. I point out that nonsurgical skin tightening will not address
platysmal issues and that any pure skin tightening procedures,
regardless of the approach, yield only temporary results, because
skin will always relax to a resting tension of 32 mm Hg. If asked, I
also advise that although nonsurgical skin tightening approaches
work to a lesser and more variable extent than surgery, they do
have the least morbidity and have no need for general anesthesia.
2. Dynamic Lines: Dynamic lines can be addressed surgically in
the forehead, but the growth in effective neuromodulator usage
and techniques have been impressive in recent years. Botulinum
toxin injections remained the top nonsurgical procedure in the
United States in 2017, with 1,548,236 procedures carried out
nationwide. Compare this to the top surgical procedure, breast
augmentation at 333,392 procedures, and you can see that neu-
romodulators continue to outpace all other aesthetic procedures.
I point out to my patients that neuromodulators are excellent
alternatives to surgery for frown lines and frontalis lines, as long
as significant brow ptosis is not present. 1euromodulators are
also the treatment of choice for crow’s feet rhytids in my practice.
3. Actinic Damage: Actinic skin damage plays a significant part of
the aging process, and if it is neglected, surgical results and patient
satisfaction are negatively impacted. For example, if the percep-
tion of skin age lags behind the perception of gravitational and
dynamic age post facelift, there will be disharmony, and the face
will appear awkward and unnatural. So, a plan to optimize skin to
a more youthful appearance is key to my surgical consultation. In
experienced hands, any resurfacing technique, such as dermabra-
sion or a series of chemical peels, can be utilized to a satisfactory
endpoint, but my preferred technique is laser resurfacing.
4. Volume Loss: :hen it comes to treating volume loss, there are
many good uses of fat injection, either as an isolated procedure
or in conjunction with other rejuvenating procedures. I have no
problem with this approach, but I believe that dermal fillers play
a stronger and more popular role due to their ease of use and lack
of general anesthesia and fat harvesting. 1o matter what your
preference is for volume restoration, the consultation is a golden
opportunity to discuss the idea of full correction. I usually state
that if there are any remaining volume issues postoperatively,
we can discuss fillers as both a ´finishing touchµ and/or a solu-
tion for future volume loss.
I realize every surgeon has his or her own approach to the con-
sultation process, but I’ve found significant success in painting this
large picture to give patients a plan for achieving full correction.
Most patients are not aware of all the possibilities available, and the
comprehensive consult serves a purpose, not only to educate them
but to inform them that you can personally provide those services
with excellence, optimizing their outcome and experience. However,
I am always respectful of any plan they choose, as long as they are
aware of the implications of those choices; therefore, we cover risks,
benefits, and expectations. As a cosmetic surgeon, I have a respon-
sibility to help them optimize safety, but also to point out that safe,
viable options may fall short of full correction and possibly high
expectations. Ultimately, patients must decide on their individual
plan based on personal goals, biases, fears, financial considerations,
recovery time and overall risk-to-reward ratio. My job is to explain
each option clearly and fully, so they can make an educated choice.
If they leave the consult with an effective personalized plan and a
long-term maintenance program that enhances their surgical out-
comes, skin health, and appearance, I know my job is done.
7.3 2̵ering WKe &RmSreKenViYe
Aesthetic Plan at Your Practice
:hile my nonsurgical consultation occasionally takes place
in my surgical office, it is most often carried out by physician
extenders located in our skin care and laser/technology center.
This is because our aestheticians and nurses are taught to offer a
comprehensive skin care plan that ties in with our practice goal
of full correction for all patients.
In my opinion, the ideal aesthetics practice should be able to
offer a wide array of surgical and non surgical services that would
anticipate the large majority of patient’s concerns. Although
difficult early in practice it, comprehensive aesthetics care should
always be the end goal.
Before I describe my thoughts regarding this comprehensive
package, I’d like to point out one approach you should always avoid.
Do not make a technology purchase, then push all patients to that
technology, regardless of their needs and wishes. This is a financially
driven approach that is understandable but not optimal and perhaps
a little short-sighted. If you must compromise, understandably, on
limited technology do not compound the problem by overselling
this treatment to some of your patients who will not benefit opti-
mally from it. Again, this financial prioritization is tempting, but is
short sighted, creating disappointed patients. Many spas fail due to
poor technology choices, as a result of inferior knowledge and/or
lack of proper funding. 1awve approach to management is especially
problematic in struggling spas. All of these potential issues must be
kept in mind and avoided if you want to provide quality treatments
and service to the patient. Remember, it is imperative to maintain
your clarity of purpose if you want a successful business.
In an ideal situation, after IPL purchase you would begin to add
devices and services that address each patient issue more specif-
ically to optimize the result. Examples might be to add a technol-
ogy that addresses pore size and texture more aggressively, body
contouring, and skin tightening.

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It is beyond the scope of this chapter to describe an in-depth com-
prehensive approach to every aging condition you will encounter.
However, to serve as a limited example, if you are to start out with
one piece of technology, an intense pulsed-light (IPL) device would
be a reasonable choice in many offices, especially if the majority of
your patients are skin types II and III. At a practice with a majority
of ethnic patients, light-based technology is more challenging due
to the melanin content encountered and resultant potential hypo-
and hyperpigmentation issues. Other energy-based devices might
be a better option, but I would encourage you to do your homework
attending Continuing Medical Education (CME) courses, reviewing
the literature, and asking experts as to the proper choice for you.
So, why do I choose IPL" Simple. An IPL device treats many
patients’ nonsurgical concerns, such as texture, pore size, vascular
issues, and dyschromia. Even laser hair removal can be addressed,
although there are better devices for that specific issue. However,
it is an excellent initial tool that will aid you in achieving your
patients’ goals to full correction. There are also many excellent
technology platforms that can be purchased with an IPL module
in place, leaving room for other laser and/or alternative energy
technology additions to the platform as your practice grows.
In an ideal technology and skin care center, you would also have
a set of devices that address your patients’ nonsurgical concerns
specifically, such as redness of the skin, dyschromia, texture, and
pore size, as well as mild to moderate wrinkles and mild skin
laxity. If you are prepared to invest the time and financial resources
to acquire sufficient knowledge and energy technologies, you can
confidently carry out a comprehensive long-term plan that will
optimize the patient’s aesthetic appearance.
In my office, such a comprehensive skin care assessment is
aided by photographic analysis. This can be carried out with
simple photographs, but it is aided greatly by modern technology
and software programs that show patients the full extent of their
damage through ultraviolet photography and digital filters. In
many programs, a qualitative and quantitative assessment can
also be rendered to place objective measurements on skin quality.
This is a great tool for patients, because it enables them to see
visible results and gain even more confidence in their progress
and, ultimately, in your skills as their physician.
7.4 The Full Correction Goal
The purpose of your doctor-patient relationship and treatment
plan should be crystal clear from the outset. sell them the latest technology or to promote the most popular
trend but rather to determine a comprehensive long-term treat-
ment plan with which to optimize their skin health and appear-
ance for life. A helpful analogy to offer the patient is to compare
skin health to physical health. 1obody would go to the gym once
or twice a month and truly expect to optimize their overall health
and fitness. That takes discipline and commitment³something
also required to achieve optimal skin and full correction.
I like to show my patients photographs of others who have com-
mitted to a comprehensive skin care plan and had better-quality
skin than they did when they started.
I point out a very important study by Dr. Patrick H. Bitter -r., a
board-certified dermatologist and founder of Advanced Aesthetic
Dermatology, that shows how patients who committed to three
BroadBand Light Therapy (BBL) treatments a year for 3 years
genetically changed their skin to a more youthful D1A expression.
BBL uses a broad band (560–1,200 nm) of noncoherent light waves
that are absorbed by the skin, and it is very popular for skin reju-
venation. After administering a regular, consistent course of BBL
treatments to a number of aged female volunteers with moderate
to severe photodamage, Dr. Bitter and his associates discovered
that the skin showed significant improvements in clinical ratings
of both intrinsic and extrinsic skin aging. An increase in epidermal
thickness was also noted. In short, this course of BBL treatments
was proven to restore the gene expression pattern of photoaged
and intrinsically aged human skin to resemble that of young skin.
Another of Dr. Bitter’s studies shows how patients who com-
mitted to at least one BBL treatment a year over a period of 5 to
11 years notably delayed the long-term effects of skin aging. The
study proved that although participants’ skin aged a median of 9
years over the course of the treatments, their treated skin appeared
to have aged only a median of 2 years or less. This indicates that
patients who maintain a regular annual or biannual course of IPL
treatments such as BBL can delay and even reverse the visible
signs of aging, including skin laxity, photodamage, telangiectases,
and fine lines and wrinkles.
Such dramatic findings make it clear to patients that it is never
too late to start treating the skin but that it takes commitment to
achieve the results they desire.
Again, details of the various full correction options are beyond
the scope of this chapter, and excellent physicians can, and will,
vary greatly in their approach. In general, daily sunscreen is a
given in every plan. However, an exact skin care regimen must be
designed based on a comprehensive skin analysis. The practitioner
must evaluate the patient’s skin type and qualitative skin issues,
as well as the patient’s concerns and commitment. Based on the
information gathered, an individualized, long-term plan can be
designed and delivered.
I strongly believe that if we, as aesthetic surgeons, maintain an
open mind and a commitment to skin care and all nonsurgical
technology, we can provide the most comprehensive and complete
set of aesthetic solutions available. :e are uniquely qualified to
deliver every need of the aesthetic patient, but we must present all
of these options confidently and clearly to the patient in the initial
consultation. We should be able to recommend the best sunscreen,
the most beneficial skin care, the latest laser or alternative energy
technology, and the most effective surgical services. Then, and
only then, can we be the equivalent of a ´full-service bankµ that
provides comprehensive, quality service and eliminates the need
for a patient ever to consider going elsewhere. If this environment
is provided, then I return to my original premise that if we provide
the best treatments and outcomes we will be rewarded with satis-
fied and loyal patients . . . and a very successful business.
1ow, the last piece of the puzzle is to recognize the patients’
challenges when it comes to staying on their prescribed plan.
They may be dedicated and willing, but what obstacles do they
face, and are there ways to help these patients minimize such hur-
dles" I have personally discovered options that greatly enhance
patient retention and loyalty. These options also enable many of
my patients to stay on plan and finally get the results they are
striving for. The business rewards financially have been equally as
satisfying. In the remainder of this chapter, I will review current
trends, options, and results seen nationally and in my practice.

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II Business Basics
7.5 The Patient Retention
Conundrum
A question that frustrates almost every physician in the aesthetic
space is this: why don’t patients stick to their prescribed aes-
thetic schedule" :e can deliver a ´perfect consultµ and spend all
the time in the world curating a carefully constructed injectable,
laser and/or skin care plan for our patients, but getting them to
comply is an almost impossible task. Many cosmetic physicians
believe they have a loyal aesthetic clientele and a highly prof-
itable business. The actual loyalty percentages vary, but when
looked at objectively, data prove that no practice has the patient
retention desired, with data showing the average U.S. neuro-
modulator patient receives treatment only 1.4 times a year. In
my practice, it remains a challenge (Table 7.1, Table 7.2).
1ot long ago, I realized that fewer than 50 of my patients were
following their schedule for injectables, and I knew that with this
lack of compliance, their results would suffer and ultimately so
would my business (Fig. 7.1). While new customers are para-
mount to any successful company, these repeat customers are the
absolute essence. 1ot only does it cost around seven times more
to acquire a new customer than it does to retain one (an average
of 800–1,000 per patient), but repeat customers also spend up
to 33 more on services and treatments.
Interestingly, of the 30 million people in the U. S. who con-
sider getting aesthetic procedures, only 10 of them follow
through with an actual treatment. This is obviously a frustrating
Table 7.1 Research on < 10,000 neuromodulator patients in 2015 and
2016
1umEer RI DnnuDO
neurRmRduODWRr WreDWmenWV
3erFenWDge RI DOO neurRmRduODWRr
patients
1
47%
2
26%
3
15%
4 or more
12%
Table 7.2 Data from Dallas Plastic Surgery (2016/2017) demonstrating
the number of neuromodulator treatments the average patient receives
annually
1umEer RI DnnuDO
neurRmRduODWRr WreDWmenWV
3erFenWDge RI DOO neurRmRduODWRr
patients
1
36%
2
20%
3
17%
4 or more
26%
Fig. 7.1 The information in the figure indicates my own personal experience implementing aesthetic memberships in my practice. Increased number
of visits per year in addition to greater spend per visit increased my yearly revenue per patient on toxins alone by over 1,000 per year.
My Toxin Results
Baseline*
1.73
3.09
79%
35%
Compliance
Transaction Value
Annual Revenue per Patient
treatments/year
treatments/year
avg spend/treatment
avg spend/treatment
annually
Dr. Burns Data. n = 786 baseline (pre-subscription) patients vs. EpiElite membership patients, n = 359. 2016. 2018.
annually
Epi-Elite Members
Growth
$.327
$.521
$.1,604
$.1,083
$441

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and challenging statistic for all of us interested in this patient
population.
So why are customers notoriously difficult to both acquire
and retain in the aesthetic industry" Unsurprisingly, financial
challenges are the most significant barrier. In recent studies, over
two-thirds of consumers who were interested in aesthetics but
had yet to try a treatment stated that cost was the main obstacle
stopping them from trying a procedure. And while we are all
acutely aware that countless ´miracleµ creams from the drugstore
work out to be far less effective and way more financially costly in
the long term, it’s not so easy to convey this to the consumer when
asking for 500 for a 20-minute injectable session.
Regular aesthetic patients are also price shoppers when it comes
to dermal fillers and neuromodulators. Rather than staying loyal
to one injector, many will look around for deep seasonal discounts
or the best local deal³often without a thought for who will be
administering their treatment. This cost-saving approach is often
shortsighted and potentially dangerous, as such treatments are
best delivered in experienced and talented hands. However, if we
can offer these treatments in a way that reduces financial barriers
and provides other opportunities for patients to stay under our
care, it will be a win–win for both the patient and the practitioner.
Fortunately, I believe our industry has an exciting new solution
to acquiring and retaining patients: aesthetic subscriptions.
7.6 What Is An Aesthetic
Subscription?
I’m certain you’re aware how the subscription model is being
executed successfully across virtually all industries at this time.
From the way we watch television (1etflix) to how we shop
(Amazon Prime), it’s clear that leveraging some kind of subscrip-
tion business model is the most effective way to win and retain
new customers while increasing the average value of existing
ones. Aesthetics is no exception.
Simply put, by offering and selling a subscription membership
to one of your patients, you create a loyal, long-term relationship
and better results that equate to both increasing and recurring
revenue.
At the time of this writing, subscription memberships are just
entering the world of aesthetic medicine, so my experience is per-
tinent, as I am one of the first to utilize such a model. I decided to
beta-test the impact subscriptions would make on my aesthetics
practice, with a primary focus on injectable subscriptions. There
are several types of subscriptions, as I mentioned previously, but
I chose a platform that structured their aesthetic subscriptions
similarly to Apple’s offering of the new iPhone. :hat this means
is that a patient does not get as much Botox as they want for a set
price; but instead they pay for the cost of their treatment over
time. It made sense, since like Apple, I was trying to get consumers
to commit to a luxury purchase over an extended period time, so
by making payments easier for consumers along with a one-time
buying decision, I felt that patient loyalty would be increased. My
decision was heavily influenced by retention data on over 50,000
injectables patients from leading aesthetic practices in the San
Francisco Bay area. :hat the investigators found was that the
average neuromodulator patient was being treated only 1.4 times
per year, while the average filler patient was being treated just 1.1
times a year. They were also able to show that 73 of patients do
not follow their prescribed treatment schedule.
Initial reporting on 35 practices from a beta test of an aes-
thetics subscription software platform showed impressive and
consistent results from the 3,000 patients who had signed up
for a neuromodulator or filler subscription. For neuromodulators,
aesthetic subscription patient retention had increased from the
average 1.4 treatments per year to 2.9 treatments per year, and
filler retention from 1.1 treatments per year to 1.6 treatments
a year. The researchers were also able to demonstrate that the
aesthetics subscription patient spent an average of 31 more on
their neuromodulator or filler each treatment and was 72 more
likely to cross-sell to other services in the practice.
As stated previously, based on these pilot data, I recently imple-
mented a personalized membership program in my own practice.
This program centers on the subscription model just described.
By empowering my patients to take control of their aesthetic
treatments, and offering them a service that allowed them to pay
for these treatments in affordable monthly installments, the busi-
ness was transformed almost immediately. I had a 79 growth in
patient compliance and an increase in annual recurring revenue of
over 1,000 per patient. In the first seven months, I signed up 377
members to a membership program (EpiElite) powered by the
subscription software. This equated to an annual lift of 381,524
in practice revenue based on a 12-month run rate.
In our model, the setup is relatively simple and was totally
customized to my practice, pricing, and marketing requirements.
Current software enables us to create aesthetic plans for our
members so they can maintain their aesthetic goals through
affordable monthly payments. It also enables us to prescribe and
personalize the brand of treatment, frequency, and the number
of units, and more important, it gives us the flexibility to change
a patient’s plan according to their concerns over time. I believe
this personalization is the absolute key to optimized results and
success in aesthetic subscriptions. It certainly has been in our
practice, as our patient satisfaction and revenues suggest.
Our current software solution has seamlessly integrated into
our working day, and there is a mobile app for patients, so they
can follow their aesthetic journey. Let me once again remind you
that the other major challenge to patient retention and staying
on plan, besides cost, is busyness. The mobile app tied to the
software solution for aesthetic subscription memberships also
sends reminders of their plan and their appointment schedule.
This app can be customized to receive texts about the advantages
of membership, specials, and individualized touches from the
physician or their service provider.
Our subscription program has significantly strengthened our
relationships with patients and simultaneously increased prac-
tice loyalty by providing members with a personalized beauty
plan that is dynamic, affordable, convenient, and extremely
results-driven. This means our patients see visible results and
keep returning to our practice (rather than just any practice) to
maintain their aesthetic goals.

72
II Business Basics
7.7 7Ke 7RS 7Kree %eneÀWV RI
Implementing an Aesthetic
Subscription Program at Your
Practice
7.7.1 Consistency Means Better Results
and Better Retention
Utilizing a subscription model gives patients stability and con-
sistency with their treatments and procedures, making it much
easier for them to stick with their recommended plan. It’s been
proven that aesthetic subscribers visit the office twice as often
as regular patients, so you can expect them to stay much more
closely aligned to their plan. To put this into perspective, 24 out
of my first 25 subscription members returned for their follow-up
toxin treatment in less than 100 days. :hen you compare that to
the baseline of 50 returning in that same period, it is a signifi-
cant impact to the practice.
7.7.2 Patient Satisfaction Means
a Bigger Spend
Members who enjoy a positive experience with their subscription
program are far more likely to spend extra dollars at the practice
than nonmember patients. As an example, studies have shown
that 72 of patients enrolled in a subscription membership for
dermal fillers will also sign up for neuromodulators, proving that
implementing a subscription model promotes full correction
due to the lower upfront cost implications. Being a member of
a practice also triggers customers to buy into a broader selec-
tion of procedures, treatments, or skin care products that may
previously have gone ignored. I do not want this discussion to
center purely on the financial ramifications, as I have empha-
sized that results are the primary focus. However, if subscription
memberships encourage patients to try other excellent services,
their results and satisfaction are enhanced. 7KH fiQDQFLDO DGYDQ-
tages and results are intimately tied together, and this cannot be
overlooked.
7.7.3 Easy Monthly Payments Mean
Expansion of Your Practice with
New Patients
As previously mentioned, price is the main obstacle for intro-
ducing aesthetics to a wider audience, so by implementing a
subscription program, reducing up-front costs to the patient,
and offering member-only prices, you automatically make
aesthetics more desirable to a wider audience. Instead of paying
500 every time they visit the practice for their fillers and toxin,
for example, patients can split these payments over the year. The
current average patient, especially millennials, buy with a pref-
erence for the subscription model. They have proven that they
much prefer a charge of 150 per month over a larger lump sum
in most cases. :e also reward our members by offering reward
treatments at 6 months and/or a year in exchange for their loy-
alty, which has proven to be a huge incentive when transitioning
patients into members. :e also offer some member advantages
in our particular practice to incentivize membership enrollment
and retention, but many successful practices offering aesthetics
subscriptions choose not to offer any additional incentive other
than the financial ease provided by the subscription itself.
7.8 Advantages I Did Not Expect
:hen I implemented aesthetic subscriptions in my office, I was
unapologetically driven by the need to drive patient retention,
loyalty, and profits. However, I must list some further advantages
that cannot be overlooked.
7.8.1 Barrier to Patient Transfer
Subscription memberships keep patients more loyal. They are
less likely to transfer to another practice that does not provide
subscription services. This barrier is not 100 effective, but if
an aesthetician or nurse leaves the practice for any reason, they
cannot transfer the advantages of the membership program you
provide in your office. In speaking with other physicians who
have implemented an aesthetic subscription program in their
office, I have discovered that most find this ability to protect your
patient base from departing staff members invaluable.
7.8.2 The Value of Data
The facts speak for themselves: few tools have offered me
more customer data than my aesthetics subscription platform.
1ot only did it make me aware of my actual retention and the
need to improve it, but also I now have access to valuable key
performance indicators in my practice, such as patient spend
per treatment, retention, cross-sell, and other data into which I
previously had little visibility.
7.8.3 Building Practice Value and
Providing Enhanced Exit Strategies
A dilemma for every physician is how to value his or her practice,
especially when trying to add a partner or sell it. ´Blue skyµ is elu-
sive to define and difficult to agree on. By bringing subscriptions
into your practice, not only do you realize immediate revenue
increases, but you secure an increased future revenue stream.
This increased stream is the reason subscription businesses are
generally valued higher than nonsubscription businesses (1etflix
is valued today at 10ð its revenue, while Blockbuster at its height
in 2004 was only valued at 1ð revenue). As a physician looking
forward to my own exit at some point in the future, I hope to
capitalize on this additional intangible benefit that subscription
has brought to my practice value.