Cosmetic surgery is a very unique specialty as it is, for the most part, totally elective. No one needs cosmetic facial surgery! Very few surgeons begin their journey as “strictly cosmetic surgeons”. Having a total cosmetic surgery practice is actually pretty rare because many “cosmetic surgeons” perform other procedures based on their background training. For instance, plastic surgeons may also do burns, trauma, and reconstruction; facial plastic surgeons may also do ENT procedures and skin cancer; oral and maxillofacial surgeons may still do implants and wisdom teeth; dermatologists may still do acne and general dermatology, ophthalmologists may still do cataracts and corneal surgery, etc. Some practitioners love this mix and others only perform the noncosmetic procedures because they have to. If a surgeon is interested in transitioning to a totally cosmetic surgery practice, he or she will eventually drop the ancillary procedures and progress to total cosmetics. I, personally, have limited my practice to cosmetic facial surgery since 2004 and there are certainly pluses and minuses to this. First of all, I love cosmetic facial surgery; it is my passion and I love going to work, so for me this specialization has been awesome. The only negative thing I could think of is the fact that shifts in the economy can affect “luxury” items, which includes cosmetic surgery. Having said this, my bottom line did not droop during the 2008 recession, but many of my colleagues did. Other surgeons will list negatives as having to deal with the sometimes fickle, unpredictable, body dysmorphic, demanding, litigious, and elective patients with unrealistic expectations. Like any job, there are positives and negatives, but most successful cosmetic surgeons I know love what they do, and the positives greatly outweigh the negatives.
The cosmetic surgery patient is truly a different animal than many of the patients we experience in residency or in a specialty practice. The biggest difference is that these are elective patients seeking an upper-class luxury. When treating a patient for trauma or malignancy, they are most frequently grateful for your skills because they are emergent. Cosmetic surgery patients, on the other hand, are totally elective and paying a lot of money for services they do not actually need. Fortunately, the vast majority of these patients have positive outcome and are happy with their treatment. Many cosmetic surgery patients may also have significant biopsychosocial implications that complicate normal interaction. Some of these patients have unrealistic expectations, some are body dysmorphic, and some are doing surgery for the wrong reasons. In this case, they may be unhappy with a perfectly acceptable surgical result and this is when things can get problematic. One of the best ways to become a great cosmetic surgeon is to choose the right patients and avoid the wrong ones. This is a skill that usually takes decades to master and will be addressed later in this chapter.
There is no more important aspect of the cosmetic surgery experience than the initial patient consult. As they say, you never get a second chance to make a first impression, and the first impression occurs when the patient phones the office to make an appointment. Unfortunately, this is where a lot of patients are lost. Many cosmetic surgery patients are “tire kickers” and will call numerous offices to discuss consultation and surgery. Having personable, friendly, energetic staff answering the phone can be one of your best referral sources. It is very common for patients to tell me that they actually saw three or four other surgeons, but due to the professionalism and attitude of my staff, they came to my office. Many barriers exist to getting a patient from the phone to the operating room and an astute front desk person will help the patient by eliminating these potential barriers. Cosmetic surgery requires multiple appointments and patients are busy. Cosmetic surgery is expensive. Cosmetic surgery can be painful, etc. A compassionate receptionist can alleviate many of these apprehensions and get the patient into the office. I can’t stress the importance of the receptionist or patient representative.
An exceptional patient service representative knows how to “answer the phone with a smile” and make patients feel comfortable. The first question they ask is the caller’s name, then they use it frequently throughout the conversation because everyone likes to hear their own name. A great front desk person can convert a question into a consult. If a patient calls to inquire “how much do you charge for Botox?” a poor employee with tell them “$11” and the conversation is over. An exceptional employee, will ask the patient their name. The patient answers “Anne”. “Thanks for calling Anne, have you ever had Botox before? Did you know Dr. Niamtu is in the top 1% of Botox providers in the country and he teaches neurotoxin techniques to other surgeons? He also uses special techniques to make the procedure painless. Can we make you an evaluation appointment?”
This great patient service representative has now converted a patient with a question into a patient with an appointment. Great patient service representatives are priceless, and poor ones can run your business into the ground ( Fig. 3.1 ).
All of our patient representatives are familiar with all of our procedures and can discuss them accurately with prospective patients. We make all receptionists spend time in the operating room observing procedures, and we also cross train all our surgical assistants to answer the phones and make appointments. This cross training allows all employees to appreciate the work of their peers and also means that they fill in in a pinch.
The Physical Plant
If you perform cosmetic surgery, you have to have an office that is as nice as your biggest competitor. I say this because it is not uncommon for cosmetic surgery patients to seek multiple consultations. They are likely to see your competitors and if their office grossly outshines yours, you are already at a disadvantage. Having said this, a poor surgeon with a great office will not succeed, but cleanliness and presentation can go a long way. Always remember, these are elective patients seeking upper-class luxury surgery. They shop at high-end stores, stay at high-end hotels, and go on high-end vacations. They are used to being pampered and being in nice surroundings ( Figs. 3.2 and 3.3 ). The cosmetic surgery office needs to be set up with this in mind. Having said this, many of my patients are middle class or blue collar, but they are spending outside of their means and expect the same environment as wealthier patients.
The cosmetic surgery office should be clean, pleasant, and in most practices decorated to accommodate females because the majority of cosmetic patients are women. The best way to set up an office is to consider your experience at a very high-class hotel and try to duplicate that in your business. Concierge care is a new buzzword, but most successful practices have known these secrets for centuries. The entire goal is to get the patient’s attention for them to come and go with positive impressions. They have to realize that you are special and “do it different”. A patient greeter, providing drinks and snacks, assisting patients with paperwork, and having educational material available, underline your commitment to patient service. Conveniences such as available computers or iPads and wireless connection are all amenities appreciated by patients.
If you are looking for a model of what to do, look at Las Vegas casinos ( Fig. 3.4 ). They totally have it right. They know how to treat their high rollers to keep them coming back. Cosmetic surgery patients are also high rollers and successful practices know how to make them feel special. They have beautiful furnishings, great smells, comfortable temperature, extremely friendly staff, and everything is clean and bright. Everyone likes to feel special. If you figure out how to treat your patients special, you will be way ahead of the pack.
The surgeon and or staff should regularly sit in the reception room and observe all the senses. Does everything look good, smell good and sound good? Are the magazines current? Is the space spotless? Every several years our administrator has a “secret shopper” who none of us know about that comes to the office to evaluate the entire experience. This can be very eye opening because we sometimes fail to see the negative things that are around us. Fish cannot see water because they are in it! Many practice management specialists say there should be no magazines in the office, only promotional material about services offered. Personally, I think patients need some diversion. Every single one of them has seen my website and marketing before getting here. Sometimes it is nice just to chill and not feel you are getting “sold” at every angle. First-time cosmetic patients are usually nervous, so I want them as relaxed as possible. They can use our computers, watch TV, or read a variety of magazines as well as have drinks and snacks, which about 99% do.
One of the goals of a well-run office is to not make people wait for long periods. In my office, we have five evaluation and treatment rooms and a relatively small reception room. My goal is to get the patients out of the reception room and into an evaluation room as soon as possible. No one likes to wait, but if you can break up the experience and keep the patient busy, the wait seems less. Once they get into the evaluation room, they have the company of a staff member and also can watch TV or review our website while waiting for the surgeon. One of the biggest simple innovations of the last decade has been the development of affordable, high quality wide screen TVs. We have 15 in our office and use them for many purposes including recreation, patient education, anesthesia monitoring, and teaching ( Fig. 3.5 ).
Cosmetic Surgery Staffing
I have always said that a surgeon can be no better than the sum of their staff. In elective surgery, there is no doubt that a great staff can and will enhance the experience and a poor or apathetic staff will drive patients away. Choosing the correct staff is never happenstance and takes years for the average doctor to figure it all out. Cosmetic surgery is very different than many specialties because it is an upper-class luxury for mostly female patients and totally elective. You have to have staff who understand and relate to the biopsychosocial needs of this clientele. My best cosmetic coordinators were not trained in surgery but rather worked at high-end women’s stores. They know how to talk to and sell to upper-class females. Some of my best front desk representatives previously worked at hotels or travel agencies. Again, they are used to catering to people with elective money to spend and who value exceptional service.
When it comes to building a great staff, the word TEAM says it all ( Fig. 3.6 ). We have a cosmetic team in my office and we all represent exceptional patient service with optimal safety and predictable and reproducible outcomes. No team gets good by happenstance. Any winning team in any sport takes hours and hours of practice and working together. A cosmetic team is no different. Each “player” must have a distinct job description and also understand the job of other team members. When you have this occurring, you can achieve synergy. This is when the total is greater than the sum of the parts. You build a great team with everyone on the same page and success is greatly simplified. This entire text could deal with staffing but needless to say, we want team players that are “win/win” people. They represent health and beauty and should look the part. They should smile, radiate happiness, warmth, and compassion and should be able to make conversation with anyone anytime. In interviews, I look for bubbly conversationalists with a great smile. Their demeanor is much more important than their job experience. I want to hire a “people” person. The job of my staff is to make me look good and they do an excellent job.
Germane to the team concept is consistent use of logos, trademarks, pictures, and so on for all office and marketing materials. This includes printed materials ( Fig. 3.7 ), promotional items ( Fig. 3.8 ), and scrub logos (see Fig. 3.6 ).
The Art of the Consult
Cosmetic surgery is my passion and I love to operate. If we could all go to our offices and simply operate, life would be perfect, but to have surgery you must have consultations. The cosmetic consultation is usually the first face-to-face meeting with the cosmetic team and the surgeon. It is an extremely important appointment; many patients will see multiple providers so making the best impression is paramount. Because most consultations begin on the phone, the front desk patient representative can be a great adjunct. They can set the stage for great patient service, explain what will happen at the consult, and get some information in advance from the patient.
From the time the patient drives onto your parking lot, they must be impressed, and the doctor and team must make sure that everything is in order. Are you easy to find? Is it easy to park? Are the grounds and building clean and classy? All of these small elements serve to add up to a final analysis and choice on the part of the patient.
When the patient walks in our door, they are greeted personally, and our staff signs them in and serves them snacks and or drinks (almost everyone want some) and makes small talk. If we are running behind, the patients are informed and kept up to date. It is a bad idea to make a new consult patient wait, it sends a very bad signal, so it is important to schedule new patients on predictable times where the office does not run over.
The patient should be escorted from the lobby to the consult room by the person who will be assisting the doctor at the consult. Furthermore, this person should accompany the same patient throughout their entire surgical experience and, this one-on-one bonding is extremely powerful at building relationships.
The cosmetic coordinator takes the patient to the consult room to begin the process. This room should be the fanciest one in your office and should have a comfortable temperature and should smell pleasant. Aromatherapy is a powerful stimulation of the senses. The first order at hand is for the cosmetic coordinator to bond with the patient by making small talk and relaxing the patient ( Fig. 3.9 ).
As a sidebar, if the patient is serious about having a large procedure or is considering multiple procedures, it is frequently helpful to have their spouse at the consult. So often, the spouse (usually the husband) may have considerable concerns about the need for surgery, the finances and other questions. In addition, he will most likely be the caregiver and it is important to realize what will happen.
For many patients, meeting a new doctor makes them very nervous. With cosmetic patients, they not only have to meet a stranger, but have to tell them and show them their biggest physical insecurities. Many patients have problems with aging and do not handle it well. This apprehension can add up to a patient who is literally perspiring by the time the doctor examines them. The best thing your staff can do before the surgeon enters the room is to relax the patient. It is also very important for the staff to compliment the surgeon. They can make you look good without sounding arrogant. People want to know they are seeing a compassionate, experienced, and popular surgeon, and your staff can really help with this.
The cosmetic coordinator also asks the patient what it is they wish to discuss and she can make cursory suggestions such as, “I believe Dr. Niamtu will want to discuss eyelid surgery, cheek implants and facelift with you.” The cosmetic coordinator will also display our website on the widescreen TV and go through specific procedure pages to discuss what we do and how we do it. She will also show the patient before-and-after pictures of relative cases. This interaction is important because it gives the patient an idea of what the doctor will discuss, provides them information on the procedures, and can shorten the surgeon’s consultation time. Having awards, publications, charity involvement, and similar accolades in plain view can be very impressive to patients ( Fig. 3.10 ).
Meeting the Surgeon
After the staff preconsultation is finished the surgeon is called into the room and introduced to the patient. This initial meeting can make or break the patient’s decision. I always shake hands with the patient and introduce myself by my first name. I believe friendly communicative contact puts patients at ease and subliminally enhances the doctor-patient relationship. A show of personal warmth, an unhurried attitude, and some small talk with the patient before getting to the cosmetic problems will be time well spent. I may ask them what they do for a living, how they heard about our office, how they are enjoying their summer, etc. Again, putting a patient at ease is an art form.
Most of our patients register online and are asked to bring a list of cosmetic facial concerns to the first appointment. Nervous patients often forget to ask key questions. Patients are also frequently asked to bring in younger pictures of themselves to see what they considered their strong or weak points and how they have aged.
The most important instrument relative to the consult is a hand mirror. All patients are given a mirror and first I ask patients to tell me them what bothers them or what they would like to change and to show me in the mirror. At this point I always begin with a compliment like: “You have a great jawline” or whatever positive feature you can start the conversation with. Because you are going to be discussing negatives, it is best to begin with a positive. Occasionally a patient will say, “Doctor, what do you think I need?” The novice surgeon should never fall into that trap. It is imperative that the patient take ownership of what bothers them or what they would like to change. A patient who cannot communicate their cosmetic problems may have other underlying problems. Some patients are embarrassed to discuss the topic and need some prodding. The other problem with answering the question “What do you think I need?” is that the surgeon may suggest a problem that the patient does not see and offend the patient.
Some practice management experts say you should never hand a woman a mirror because it is offensive to make her look at her flaws. I do not necessarily agree with this, but I do use methods at consult other than a mirror. An alternative to using a mirror is to take several pictures of the patient just before the consult and project those images on the widescreen monitor. This can have great impact when showing patients their aging changes. Also giving the patient a copy of the pictures to take home can go a long way in having them realize their aging problems, especially in the lateral view, which no patient likes to see. A more digital means of avoiding the mirror is to use an iPad to take front, three-quarters, and side views and share it with the patient. Using a free app such as Penultimate ( www.evernote ) allows the surgeon to write or draw on the photo, and this can also be emailed, texted to the patient, or printed ( Fig. 3.11 ). This allows the patient to leave with notes and drawings. Another simple solution is to take pictures on a smart phone and quickly and simply project them on the widescreen with Apple TV or similar application.
Although I developed one of the original digital imaging systems in the 1990s, I am not a fan of surgical predictions. Firstly, they are time consuming as the doctor or staff plays around with digital surgery, which can waste precious patient time. At one time the cool factor of digital imaging would help promote a doctor or sell a case but today I feel that it is blasé. Secondly, this is simply a digital cartoon. You can make any patient look like anyone if you desire. The accuracy is often suspect and can also give the patient a false hope of what to expect. Having said this, I have friends who love surgical predictions and feel that it truly enhances their consults.
The best way to discuss cosmetic deficiencies is to make the consult an educational experience. I explain to the patient that I am going to discuss their entire head and neck in terms of diagnosis and potential treatments. I further explain to them that this does not mean I feel they need all the discussed procedures, but that they are possible options.
The most orderly means of systematically discussing facial aging and potential treatment is to explain to the patient that the face is divided into thirds, and we will discuss the upper, middle, and lower third then discuss the skin as a separate unit. During this discussion, the surgeon should never assume, for example, that the patient understands the difference between brow aging and eyelid aging. Always stay elementary when explaining diagnosis and treatment. Many patients have never heard of cheek implants or understand what a browlift or facelift does. If patients are put off by discussion of multiple procedures, and if I sense the conversation going that way, I consider this patient more conservative and stay closer to their main concerns. As I talk to the patient, I include my cosmetic coordinator in the discussion. I may say, “Mrs. Smith, I think you are a great candidate for laser skin resurfacing. Don’t you agree, Jenny?” ( Fig. 3.12 ). This helps to involve more people in the discussion, puts the patient at ease, and reinforces my diagnosis. My assistant is continually recording bullet points of the consultation discussion and also prepares a form to give to the patient when they leave that lists the discussed procedures and their respective fees.
I prefer to do my cosmetic facial consults in a high-end dental chair that can also double as a treatment platform for injectables or minor procedures. In almost every consult, I recline the chair and have the patient elevate their chin and look in the hand mirror ( Fig. 3.13 ). This takes gravity out of the equation and provides a surprisingly accurate estimation for facelift, browlift, or cheek implants. I have done this for years and it goes a long way to help the patient understand and preview a potential result.
A very important concept is not to assume that any patient really has an appreciation as to what any procedure is or does. We do surgery all day, every day, but they may do it once in their life. It is our job to clearly define the correct diagnosis and explain in an elemental way what procedures are available and what each one will and will not do. The more “props” you have on hand, the easier it is to convey how procedures are performed. In this digital age, the standard for consultations would include animations, videos, and photos. The best place in the world for me to get all of this is from my own website. Our standard protocol is to have the cosmetic coordinator open our website on a widescreen TV in the consult room ( Fig. 3.14 ). Then, the staff member will review the procedures that the patients interested in. While on the web page, they can view and discuss procedural examples, animations, surgical video, and thousands of before-and-after images. The consult should definitely be an educational experience and I think this is the best way to do it.
I feel the best way to perform a consultation is to tell the patient that “today we are going to do a full examination and discuss what aging changes you have and what nonsurgical and surgical options are available.” I further explain that “cosmetic surgery is totally elective and just because I point out some aging or discuss a procedure, it does not mean that you need or want that procedure.”
It is very important for the staff and surgeon not to appear “pushy” in terms of having surgery. No patient likes a high-pressure sales pitch, and there are many aggressive offices out there that push too hard, and it is very apparent to the patient. I really make a point to tell the patient that I really do not care what they do or do not do. I love doing surgery and if the procedure is good for the patient it is good for me. I may make suggestions, but if I see that a patient is very conservative or resistant to multiple procedures, I immediately back off from discussing a comprehensive treatment plan. Of utmost importance is to address the patient’s primary concern first. If a patient presents and says “I hate my neck”, then you do not want to begin the conversation about their eyelids. Stay focused on what is important to the patient and after their major concern is thoroughly discussed, other areas can be addressed. As stated, patients are frequently nervous, and the office has a lot of information to present, so it is not hard to confuse the patient or skip over important details. The best way to avoid this is to do the same thing in the same order at every consult.
After introducing myself and making some small take, I get down to business. I either say: “My staff says you are interested in a facelift.” Or I ask the patient: “What are we discussing today”. Both of these set the stage for the patient to begin dialogue. Sometimes they are less forthcoming because they are nervous, embarrassed, or just not good communicators. For times like this, I say: “When you look in the mirror, what bothers you the most?” I frequently use myself as an example saying: “When I look in the mirror, I see a big bald head, so I would love to have hair”. That usually brings out a giggle and then they relax and tell me what bothers them. I have to say, as I have gotten older and now have some early jowling and neck skin, I can use myself as a model to discuss aging and this helps the conversation because I “feel their pain”. Once I address the main problem, I tell the patient we are going to do an educational aging analysis in a specific order, addressing four distinct areas. The areas to be discussed are the upper face, the middle face, the lower face and the skin. I then repeat that list to make sure they understand the order ( Fig. 3.15 ).
While the patient looks in the mirror or at a picture, I point out aging problems in the following areas:
Brow and forehead complex
Lower face and neck
After I discuss each area, I present nonsurgical and surgical options, and my staff record the procedures and the appropriate fee. Once we discuss all the aforementioned areas, I tell the patient that we are building their “cosmetic menu”, that every patient has a different menu, that some patients “order” everything on the menu, and others may only “order” one item. I reinforce that they should only consider procedures important to them and not let our list influence their decisions. By this time, we have also discussed their health history, recovery window and budget. My average patient is a candidate for “3 Ls” and a “C”. That translates to lift, lids, laser and cheeks. These are the most commonly combined cosmetic procedures in my practice.
At this point I tell the patient that I have done all the talking; I ask them for their input and I sit back and listen. I, one more time, review their “menu” and tell them that I will leave them and my cosmetic coordinator to discuss further details (finances, scheduling, etc.). Before leaving the room, I personally hand each patient my business card with my personal cell phone and email. Most patients are quite surprised by this because many doctors hide from their patients. I tell my patients if they cannot call their surgeon, then they have the wrong surgeon. This availability has a large impact on patient choosing their surgeon. I shake the patient’s hand, thank them for coming, ask them how they heard about our office, and one more time ask them if there any further questions. The average time for the consult is 45 to 60 minutes and the actual face time with me is about 20 minutes.
Although for years, I never charged for consults, as we have gotten more and more busy, I instituted a $75 consult fee that is applicable to any product or service. This has eliminated a lot of “tire kickers” or patient who were curious but not serious about having cosmetic surgery. This has greatly improved our schedule to concentrate on more serious patients.
When I leave the room, the coordinator sits back down and continues the conversation with the patient to discuss finances, offer literature about payment plans, and gives the patient a professionally made presurgery package containing a lot of information about our office, our doctor, and the presurgical experience ( Fig. 3.16 ).