LIFESTYLE AND SOCIAL HISTORY

A thorough understanding of the patient’s lifestyle and expectations is necessary to avoid problems. A 60-year-old retired longshoreman may dramatically differ in his perception of aging from that of a 60-year-old investment banker struggling to survive in a rapidly changing and youth-oriented industry. A 38-year-old happily married mother of four may have totally different goals from her identical twin who is in the process of a divorce and has no children; the former may be content with some minor rejuvenation, whereas the latter may seek dramatic lip enhancement or alterations of facial proportions.

Operating on a patient who has not told a spouse, significant other, family member, or friend of a planned procedure or whose husband or lover is angry about the planned procedure will usually make the postoperative course much more difficult. A person’s career and support system (relationships and family situation) can be crucial to ensure that they have realistic expectations and to help the patient through the procedure and recovery period.

GOALS AND EXPECTATIONS

The greatest challenge at the first consultation is identifying the patient’s goals and expectations. Eliciting the actual reasons for requesting surgery or the real source of concern can be an ordeal; however, it is well worth the time invested. The surgeon who fails to do so is destined to fail. For example, an aging patient complains that her lips make her look old. Coleman structural fat grafting will give her fuller, tighter lips and eliminate the wrinkles—a completely successful result to the surgeon—but the patient returns months later unhappy because the corners of her mouth still droop despite all the time and money she invested. It is a problem that the surgeon had no idea that the elimination of the marionette grooves was the patient’s major concern. Structural fat grafting will predictably reduce wrinkles around the lip, improve lip contour, and even improve the texture of the skin in the marionette region; however, eliminating the downward turn of the corners of the mouth is more difficult. As a result, the operation may be a technical success, but the patient remains dissatisfied.

I usually ask the patient, “Why are you here?” The patient typically responds, “Because of my face,” “my eyes,” or “my smile lines.” I ask her to be more specific. If a patient says simply, “I am getting old,” I remind her that unfortunately I cannot change her chronologic age, but rather I need to know what facial changes that accompany the passing years cause her distress. Typical responses include wanting the face smoothed out, the eyes lifted, elimination of bags and pouches, or a desire for bigger cheeks. I want to know why the patient wants a smoother face or bigger cheeks. I am interested in what she perceives as the problem with her face or nasolabial folds. Does the patient think she has “sad” or “tired” eyes? Do her nasolabial folds make her look disdainful or like she smells something putrid? Does she think her face is too masculine, or does he think his face is too feminine? I try to avoid putting words into patients’ mouths; I prefer to let them identify the actual problems that have motivated them to seek help.

PREVIOUS AESTHETIC PROCEDURES

Obtaining a complete history of a patient’s past aesthetic procedures that could influence the planned structural fat grafting is not as simple as it would appear. Many patients are not forthcoming with details of past procedures. Even though patients are given an intake form on which to list prior aesthetic surgery procedures they often provide an inaccurate account, especially if they have had many procedures.

The surgeon should carefully review past procedures to be sure nothing has been forgotten or overlooked. A large percentage of patients will not volunteer information about a prior rhinoplasty. (“Oh, you’re right. I forgot! But it was done such a long time ago that it really doesn’t matter.”) They frequently fail to mention forehead lifts and upper eyelid surgery. Many of these patients consider eyelid and brow surgery to be parts of a facelift and do not think to mention them separately. Many do not remember having had a chin implant until I point it out to them. Most commonly patients fail to list revisions of procedures: “Oh, I forgot to tell you that I have four revisions of my nose surgery; but each one was just a little procedure… except for the hip bone graft.”

If the patient has solid cheek or chin implants, the surgeon should try to find out what types of implants were used. It is particularly important to determine whether silicone gel–filled implants were used because of the risk of perforation. Also, a history of infection around the implants may indicate the presence of significant scarring, which will make structural fat grafting more difficult.

In my experience, injections of silicone and even fat are the procedures that patients most often neglect to mention. Many women who have had silicone injections will not volunteer this information unless asked directly. Even if they disclaim any injections on the intake form, it is advisable to ask if they have had silicone, other fillers, or fat injections. Often a patient when directly queried will suddenly remember that she had a series of 15 injections of silicone 10 years ago. Previous procedures can influence the success of any planned procedure. For example, placing structural fat under silicone can push out and tighten the lumps of scars surrounding the silicone, causing unpredictable surface irregularities.

Because the presence of scars on the skin can influence the approach for placement of fat grafts, the history should include information about skin biopsies, punch biopsies, and so on.

MEDICAL HISTORY

Because Coleman fat grafting is invariably an elective procedure, candidates with a poor general health status should be approached with caution. The primary physician and anesthesiologist should confirm the patient’s ability to undergo the chosen type of anesthetic.

Other special considerations are relevant to candidates for structural fat grafting. Problems with bleeding, bruising, and unusual swelling after prior procedures should be addressed to prepare the patient and surgeon for similar problems. Of particular importance is the effect of certain medications on platelet function. A list of medications to avoid is given to the patient at least 2 weeks before the planned procedure date. An example of such a list is given in Box 2-1, but the surgeon is responsible for ensuring the accuracy and currency of this information at the time of each patient’s procedure.

A neurologic history is essential. Fat infiltrated into the muscles of a patient who has recovered from a facial nerve injury or Bell’s palsy may act as a stent, inhibiting movement in the affected areas of the face. Any history of psychiatric problems and the current status of these may require special attention to prepare patients for the postoperative period. A history of any outbreaks of fever blisters on the lips is solicited to determine if herpes simplex prophylaxis is indicated. Obviously, a history of allergy to penicillin and especially to cephalosporin is important, because these are the drugs of choice for prophylaxis or treatment of infections. Because smoking may impede the neovascularization of the grafts, and subsequent persistence of the grafted fat, I actively discourage patient smoking before and after fat grafting.

It is also important to inquire about the patient’s use of holistic medications. Today many patients use herbs and supplements, and the physician needs to be knowledgeable about these substances and their possible effects on the surgical patient. These agents should be treated as drugs that may have an impact, either negative or positive, on the procedure and the patient’s recovery. I recommend supplements to aid in healing and recovery; these recommendations vary from month to month, depending on current scientific studies and anecdotal information. I also provide patients with a list, which is frequently updated, of herbs and supplements that are potentially harmful to any patient undergoing surgery; a recent version of this list is provided in the Box 2-2.

Body weight is a factor that must be addressed. If patients have any plans for weight reduction, I consider delaying the procedure until they have attained their desired weight. The amount of facial fat should remain constant over a period of time so that the volume that will need to be placed can be assessed accurately. I rarely advise a thin person to gain weight before the procedure. I have found that such a person will return to her former weight in a relatively short period of time. Obviously, as body weight fluctuates so will the volume in the areas in which fat is placed. The volume lost will be a combination of both intrinsic fat and transplanted fat. In any case, the patient will have been undercorrected for her usual body weight. Similarly, I advise patients against gaining significant weight because the transplanted fat may expand.

Although I have successfully transplanted fat in several patients with autoimmune diseases (ulcerative colitis, rheumatoid arthritis, and systemic lupus erythematosus), I have noted unusual postoperative problems in several patients with chronic fatigue syndrome, specifically prolonged swelling and pain in donor and recipient sites. Therefore, it is important to identify a history of chronic fatigue or similar syndromes and forewarn such patients of possible complications.