INTRODUCTION
Cosmetic practices have a growing need to associate additional specialized services, including those offered by aestheticians. From the physician’s perspective, the influx of managed care, reduced insurance reimbursements and rising malpractice insurance premiums have severely impacted on revenues and the costs of doing business. Physicians have an unavoidable need to adapt to this changing marketplace.
At the same time, baby boomers are becoming more focused on achieving or maintaining a younger, more vibrant appearance, and expectations have opened the door for many professionals to enter the aesthetic arena and for consumers to seek out their services.
For the physician looking to develop an aesthetic healthcare niche, there are a number of obstacles to overcome, including lack of time to develop the expertise and knowledge about the issues surrounding their new endeavor. Here is where the aesthetician can step in to provide many services of benefit to both the physician and the patient.
WHAT IS IN IT FOR YOU, THE PHYSICIAN?
‘How much time do you presently spend with your patient?’ If the answer to this question has you pausing for reflection, that is intended. The patients of today have high expectations for medical care and, with the high cost of their medical insurance premiums, patients are demanding a right to quality time with the physician and staff. The physician must offer the cosmetic patient a complete informative consultation, including a medical evaluation, treatment plan and statement of costs involved. Once the physician has completed the initial phase of a medical evaluation, the aesthetician can work with the patient for a skincare evaluation and treatment. The time allotted for this session may vary depending on the procedure and/or diagnosis, but by having the professionals working to supplement one another’s roles, the patient is generally the beneficiary.
The aesthetician is an integral member of the healthcare team in a cosmetic medical practice. The aesthetician helps both the physician and the consumer by reinforcing the proper usage of pre- and postoperative medications and home-care instructions.
Acting as a liaison between the patient and physician, the aesthetician is in a position to educate the patient and reinforce compliance to pre- and postoperative instructions and care.
Women, being social animals by nature, confide and trust their aesthetician and like to discuss with them anything and everything. It is only natural that the physician’s aesthetician is privy to information not heard by the doctor, including their dissatisfactions and happiness with treatments and outcomes. This becomes an extremely relevant tool, not only in educating patients and preparing them for the different treatments and possibilities and their post-operative care, but also in guiding the physician in changes of proposed plans and goals during the patient’s treatment. It is important for the physician to carefully assess patients seeking cosmetic surgery to be sure that they are good candidates for the procedures, both physically and psychologically. The aesthetician can contribute to this assessment by communicating with the physician about any additional information that may impact on the patient’s care. When such communication between physician and aesthetician is open and ongoing, the patient is ultimately the beneficiary.
ARE THEY PATIENTS OR CLIENTS?
As some traditional medical practices strive to achieve a more cosmetic practice environment, a new breed, the medi-spa, emerges, offering all sorts of cosmetic services. In such an environment, the line between patient and client begins to get blurred. A patient, as described in dictionary terms, is ‘… one who is suffering an ailment, disease or is a victim’. The use of the word ‘client’, on the other hand, is described as ‘… a future customer, buyer, purchaser, service user’. Based on dictionary definitions, the use of the word ‘client’ better suits what today’s cosmetic patient is all about. As the lines become blurred, the dilemmas and ethical considerations seem to spawn. Some physicians believe that those they treat are still patients, as they come seeking sound advice from a qualified physician who holds a medical degree. Others think the changing face of medicine and infiltration of managed care have forced them into taking a hard stand against the traditional views and have adopted client terminology instead.
It is this author’s belief that they are still patients even though we do market to them as future consumers or clients of cosmetic services. The bottom line is that, regardless of the approach to obtaining each client (i.e. marketing), the care they receive must be of equal quality, regardless of patient/client terminology.
THE WORK OF AN AESTHETICIAN IN A MEDICAL PRACTICE
This chapter is not a textbook of medical aesthetics, but it is appropriate to outline in broad terms what procedures the aesthetician working in a medical practice is likely to carry out. The work can be divided into two broad categories:
- 1.
preparation of the skin for cosmetic or medical procedures
- 2.
postoperative care of the skin, for example lymphatic drainage to assist in reduction of bruising and swelling, camouflaging cosmetics to cover scars postoperatively, micropigmentation for reconstruction or cosmetic purposes, electrolysis or laser light sources for unwanted hair removal, and more.
SKINCARE SERVICES BENEFICIAL IN A COSMETIC SURGICAL SETTING
Preoperative Care
The care given by the aesthetician 4–6 weeks prior to cosmetic surgery may consist of a deep cleansing facial, which may include a chemical exfoliation using a variety of different products that essentially exfoliate the skin. The surgeon prepares the skin by prescribing to the patient a tretinoin or glycolic preparation. The aesthetician performs treatments that can optimize the surgical outcome through procedures such as removal of comedones and hydration of the skin.
One aspect of these treatment visits that is often overlooked is the ability of the aesthetician to monitor the state of the patient through the preoperative phase. Patient compliance to the proper use of topical medications and starting the prophylactics phase of treatment with the antiviral or antifungal medication can also be monitored. The patient who may be experiencing second thoughts about the procedure may express those concerns to the aesthetician, and they can be immediately brought to the physician’s attention.
Chemical Exfoliation
There are two purposes for the use of the word ‘exfoliation’ as opposed to ‘chemical peel’. The first is to clarify the fact that aestheticians are not physicians performing ‘peels’. The second purpose is to ward off problems with proposed legislation by the Food and Drug Administration concerning the use of alpha-hydroxy acids (AHAs) by aestheticians for professional use.
The National Coalition of Estheticians, Manufacturers/Distributors & Association ( www.NCEA.tv ) is a coalition of active skincare associations, companies and individuals who have united to establish standards and best practices, and provide political representation for the profession to state legislators and licensing boards. They have taken the position that appropriately trained aestheticians, who have completed a mandated course including theoretical and practical applications, be allowed to perform chemical exfoliation procedures.
The NCEA recommends that aestheticians abide by federal, state and local regulations. There are risks involved with using higher percentages of AHAs that require the skill of a properly trained physician. There is not one state of which this author is aware that allows the aesthetician to:
- (a)
use treatments that go below the stratum corneum, or
- (b)
perform invasive procedures.
Tissue Hydration
The hydration of the skin is a primary focus of aesthetic treatments and is one of the considerations to look for in a skincare evaluation.
Comedone Extraction
The extraction of comedones has long been a part of the ‘facial’ treatment process. Some state aesthetician boards do not allow the invasive use of implements, therefore the aesthetician is taught to ‘prepare’ the skin for extractions using exfoliants or preparation masks, galvanic desincrustation and steaming (the most widely used procedure).
Lymphatic Drainage
Manual lymphatic drainage massage is a hands-on technique that enhances the movement of lymph and connective tissue fluids in the body and promotes the normal, healthy functioning of the lymphatic system. A highly specialized set of massage techniques designed to promote the movement of lymphatic fluids was developed in the early 1930s by Emil and Estrid Vodder. This technique came to be known as Dr Vodders’ manual lymph drainage (MLD). While there are several forms of lymphatic drainage massage in the world today, all owe their origins to the work of the Vodders. MLD has been widely employed in Europe, where the technique is practiced in hospitals and clinics. It is recognized by the Austrian and German government health insurance plans. Only recently has the technique become more widely known and practiced in the USA.
Mechanical methods of lymph drainage work on a similar premise of manual, but a machine with either a pulsating suction or a constant flow is used to accomplish similar goals. The Lymphobiology® system developed by Catherine Atzen, San Jose, CA, is one popular device among practitioners of lymphatic drainage.
Cosmetic Camouflage Makeup
The use of cosmetics for camouflaging redness and swelling has become a necessary part of the physician’s cosmetic practice. The patients of today require a ‘quick-fix’ in order to return in a timely fashion to their daily chores and routines. Also of importance are the thousands of people who use this technique on a daily basis to simply cover burn scars or other injuries that require more opaque make-up coverage than standard cosmetics offer.
Within the medical setting, this type of service is essential, especially with the postlaser resurfacing patient, who may have prolonged erythema. The camouflage make-up manufacturers offer a wide range of purchasing options for the physician and aesthetician wanting to incorporate this service into their practice and business. The dilemma, however, is whether to charge the cosmetic surgery patient for this ‘extra service.’ The response to this is ‘no.’ Another important point is to know that most aesthetic schools do not teach camouflage make-up as part of the standard curriculum. Training can be received at postgraduate facilities and from manufacturers of these products.
Dermal Micropigmentation/Permanent Cosmetics
Implanting pigment into the upper dermis is also known as permanent cosmetics, microstipling and tattooing. The enhancement of eyeliner, lips lines and brows are only a few of the cosmetic applications. Tattooing is an art form that many practitioners and consumers aspire to. The procedure has gained new importance within the medical practice with greater application than just cosmetic tattooing. The reconstruction of a nipple areola, treatment for loss of pigment and filling in of ‘hair’ for alopecia areata have presented the physician with better options for those patients. The state laws vary as to who can perform these procedures and under what conditions, so be sure to check references or contact a professional organization, such as the Society of Permanent Cosmetics Professionals ( www.spcp.org ).
Microdermabrasion
Microdermabrasion, sometimes referred to as microabrasion, is one of the latest procedures for skin exfoliation. Like a miniature sand blaster, the moving handpiece impasses fine particles, known as corundum, against the face. (Corundum is an aluminum oxide mineral from which the gemstones ruby and sapphire and the abrasive material emery are made.) Corundum is an inert substance, lacking in any known active properties. Machine manufacturers make different models for use in the medical office and the salon.
The NCEA regulates microdermabrasion practice and licensing to include theoretical and practical applications as part of their core curriculum or as continuing education modules.
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