Best Practices

Best practices for cosmetic dermatologic surgery pertain to various elements of patient care: patient selection, the cosmetic consultation, development of a treatment plan, selection of procedures, performance of procedures, management of adverse events, and follow-up ( Box 1 ). Cosmetic dermatologic surgery is a broad area, and individual variation is the norm. General best practices are described in this article. Practices specific to laser and light treatments, whether cosmetic or medically necessary, are reviewed elsewhere in this issue (See Murad Alam, Abigail Waldman, Keyvan Nouri, et al: Practice and Educational Gaps in Light, Laser, and Energy Treatments , in this issue).

Regarding patient selection, best practice includes avoiding procedures on patients with body dysmorphic disorder or unrealistic expectations. Psychological concerns are often integral motivators for patients seeking cosmetic procedures, so a necessary next step is a cosmetic consultation where the patient and dermatologist get to know one another; the dermatologist understands the patient’s concerns, preferences, and risk threshold; and the patient comes to understand what is possible, and how much it may cost in terms of time, money, risk, and downtime. At the culmination of the cosmetic consultation, a treatment plan is developed that entails one or more procedures delivered over a defined time window to achieve specific objectives.

Cosmetic dermatologic procedures are safe outpatient procedures usually performed under local anesthesia. Best practice includes using Food and Drug Administration–approved drugs and devices, or other appropriate mechanisms, in a manner that poses minimal risk to the patient and is associated with a reasonable likelihood of success. Safety is particularly important given the elective nature of cosmetic procedures, but it is also crucial to convey to the patient that all risk cannot be eliminated and that serious adverse events, although unlikely, can occur in the absence of any treatment error.

Copious published literature and information about customary practice discussed at national and regional professional meetings can clarify procedure technique. Guidelines for care and consensus statements regarding best approaches to care are available for various procedures, including liposuction, fillers, neuromodulators, and lasers and energy devices. Similarly, current literature and expert groups can be consulted regarding management of any adverse events that may occur.

Cosmetic dermatologic treatments are often done in series, or may have a temporary benefit, so routine follow-up includes determining appropriate intervals for retreatment, or additional touch-ups. Best practice, as defined by such flagship professional societies as ASDS, is that any personnel delivering procedures be well-trained in that procedure, and if not a dermatologist themselves, be supervised by a qualified dermatologist.

Current Practice

Some newer materials are not used by all practitioners, and some more advanced techniques are not widely practiced. Cosmetic consultations and treatment plans may be limited by the scope of procedures offered by a particular practice or practitioner. Because of the rarity of adverse events, rare adverse events may be seen more infrequently in lower volume practices, which may consequently be less experienced in their treatment. Some procedures are delivered by dermatologists, and some are delegated to ancillary staff, such as mid-level nonphysician providers, trained by them and under their direct supervision. Some dermatologists are more likely to delegate procedures. State government regulation regarding scope of practice and delegation of cosmetic procedures is limited. Cosmetic procedures performed by less-trained staff seem to be more likely to result in adverse outcomes and litigation.

Gaps and Their Classification

Gaps include slow or variable adoption of novel procedures, with some practitioners more likely to add these to their clinical armamentarium. Additionally, practitioners may also vary in how many different procedures they offer. As a result, patients may be more or less able to obtain particular procedures depending on the dermatologists they select. These gaps pertain to knowledge, skill, attitude, and practice.

There is a relative dearth of high-quality posttreatment patient-reported outcome data. In particular, patient preferences and satisfaction are poorly understood in the context of cosmetic procedures. There are few reliable standardized measurement tools to assess clinical outcomes after cosmetic procedures. Comparative effectiveness research that evaluates the effectiveness, cost, longevity of effect, patient acceptance, or safety of procedures for similar indications is in its infancy. These research gaps impact the knowledge available to practicing dermatologists.

Barriers and How They May Be Overcome

Principal barriers include the rapid rate of change in cosmetic dermatologic surgery, with this inhibiting the ability of dermatologists to stay fully trained in the latest techniques. A related barrier is the medical rather than cosmetic emphasis of many dermatologists who perform some cosmetic procedures; such dermatologists may have limited time to perform cosmetic procedures and may lack the interest to add low-volume or resource-intensive techniques to their practices.

From a patient standpoint, it is difficult to ascertain which devices or procedures may be most effective, and which practice is best for their needs. Patients are bombarded with myriad advertisements and social media sites promoting cosmetic procedures and individual practitioners, and patients can struggle to determine which information sources are most credible.

From a research standpoint, a major barrier is the limited funding available. Federal grants are rare for investigations related to cosmetic procedures. Third-party payers, who do not reimburse cosmetic procedures, are unlikely to invest in clinical or comparative effectiveness research. Most relevant research is performed by drug and device companies, and is narrowly targeted to obtaining Food and Drug Administration clearance or approval. Research performed by entities with a principal financial interest in the success of the products being tested may be subject to obvious potential conflicts of interest. Manufacturers of cosmetic products prefer to avoid comparative effectiveness research that may show their products to be less effective than competitors’. In addition, cosmetic procedures are inherently difficult to compare because common treatment approaches may include several different types of procedures performed serially or in parallel over some period of time. Therefore comparing a single treatment of a particular type with a single treatment of a different type may not yield information that is clinically relevant. It may also be difficult to find investigators who are equally expert in the procedures being compared. Finally, few useful outcome measures for delineating procedure success are available. Metrics for assessing treatment success are often unreliable subjective global measures based on brief, nonvalidated patient or investigator questionnaires.

To overcome the training problem posed by rapid change and advancement in cosmetic procedures, there is a need for improved, increased, and more accessible training. Currently, training is provided mostly by product manufacturers or distributors, specialized education companies, and major professional societies. Manufacturers have detailed information about their own products, are highly incentivized to increase use, and have clinical experts on staff who are able to provide technical training in the use of their products. However, manufacturers may be less motivated to point out the limitations of their products or procedures, or to suggest alternatives that may be preferred in certain situations. On the other hand, manufacturers may be able to send trainers directly into dermatologist offices, thus conveniently educating dermatologists who do not need to take time off to travel to other venues. Manufacturers are highly motivated to provide training that minimizes the risk of adverse events, which could reflect poorly on the product. Specialized education companies may be able to provide a more balanced education than manufacturers. Professional societies can provide World Wide Web–based education or courses at national or regional meetings, they exist mostly to serve their members, and are generally not-for-profit. Training in cosmetic procedures can be improved by an increased effort by manufacturers and professional societies to provide on-line education that dermatologists can access at their convenience. This education should be practical and concise, and may make use of animations that illustrate treatment technique. Routine in-office training of dermatologists by clinical staff employed by the manufacturer would also help ensure that dermatologists are up-to-date regarding the latest products and their use.

Manufacturers may also choose to support research into medical indications for devices and drugs that already have well-established cosmetic indications. At present, given the dearth of reimbursable CPT codes for such products as lasers and injectables, and the consequent uncertain insurer reimbursement for these, manufacturers have focused primarily on the self-pay, cosmetic market. Research on medical indications for approved cosmetic products and procedures is therefore often ad hoc and unfunded, comprised of individual case reports or case series from enterprising physicians. Growth in the number and quality of medical indications may be hastened if manufacturers invest more research in this area.

The barrier posed by limited research funds is an imposing one. Comparative effectiveness research is to some extent supported by the professional societies, such as the Dermatology Foundation, the ASDS, and the American Society for Laser Medicine and Surgery. The amounts provided are modest, and could be increased significantly. Mandating more extensive research commitments by fellows in training could create an enlarged body of young, trained experts in clinical research to conduct future investigations. The creation of on-line databases to pool data across centers, as has already been initiated by some groups (eg, Dermbase), could be continued and expanded.

Core outcome sets can be developed for cosmetic procedures so that effectiveness, safety, and tolerability can be compared across studies and procedures. The IMPROVED group is currently working on such core outcome sets, which include investigator-rated outcomes and patient-reported outcomes. Once core outcome sets are implemented, patients and physicians will be better able to select procedures and products that are most suited to a particular patient’s circumstances.