The Cosmetic Clinic: The Strange Side of Cosmetic Dermatology - By Kenneth Beer, M.D. In the course of everyday practice in the world of cosmetic dermatology, we encounter many requests — some standard and some very unusual. Some patient requests have been too bizarre to comply with while others may not fit my esthetic choices or lifestyle but seemed to be consistent with a given individual’s goals and did not seem to have significant potential to cause harm. While I would not be a party to a “cat woman” creation, I do try to listen to my patients and help them attain their goals when they are reasonable. Knowing what’s reasonable and what’s not is key to success.   Most Memorable Odd Requests One memorable patient was in the midst of a sex change operation. From a cosmetic dermatology point of view, this was complicated and involved laser hair removal and soft tissue augmentation. The individual involved was going from being a man to being a woman. We did laser hair removal of his face as well as his pubic area. After several sessions, he had a female distribution of hair at both areas and was pleased. To soften some of the male features, soft tissue augmentation was performed. This patient, although unusual, was pleased with the results and very pleasant to deal with. Some of the models that we deal with request unusual amounts of soft tissue augmentation. For instance, we can inject several syringes of soft tissue augmentation material into the lips to the point where they look like a duck.  To them, this is not only an acceptable endpoint but a desired one. While this may not fit my esthetic, no one is getting hurt and since it brings them satisfaction, I am happy to help out. I have had requests to put Restylane into unusual locations such as the nipples. They are not frequent requests but the ones I have done worked out well. Technically, these injections are simple to perform although one has to wonder about whether the patients simply have too much time on their hands. Obviously, for those physicians injecting silicone, the breasts are an area fraught with difficulty and an area best avoided. Perhaps the least gratifying request that I fulfilled was that of a 92-year-old woman who insisted on being treated with Restylane and Botox. It seems that her 70-year-old sister-in-law had the same treatment and looked great. After trying to explain to her that soft tissue augmentation and treatment with botulinum toxins was not going to be particularly helpful, she convinced me to give it a try. After 3 ml of Restylane and 50 units of Botox, she did in fact look better.  Although I thought she now looked about 90, she was pleased with the outcome. Go figure. Patient Requests To Avoid Part of being a good physician is to remember the Hippocratic Oath and do no harm.  Part of being a cosmetic physician is to embrace the patient’s goals and desires and incorporate them into your treatment algorithm. The difficult part of caring for some patients is figuring out where the line between these two sometimes conflicting forces lies. I have heard of injections of soft tissue augmentation and Botox injections into the genital area. One or two patients have discussed this with me but it, as they say, is a place I won’t go with fillers and toxins. A useful guide to avoiding bad outcomes with patients wanting unusual injections is to avoid patients who are simply not going to be happy no matter how well you comply with their requests. These patients are typically easily spotted. One common clue is when your longtime medical staff tells you they have a bad feeling about the person. A second red flag is when the patient is requesting a somewhat unusual request and is being disparaging about a physician who had previously performed this — these people are usually impossible to make happy and you are better off not treating them.   Don’t Let Ego Get in the Way A mistake I made early on in my career was letting my ego override my IQ and attempting to treat difficult patients with my “superior patient skills”. Inevitably, this resulted in a patient who was not happy with the outcome — not because the result was bad but rather because the patients wasn’t happy before treatment. One other important way to avoid problems when attempting uncommon treatments is to avoid being complimented into trying something that you know has a high probability of resulting in a poor clinical outcome.   For instance, patients will sometimes try to talk physicians into using materials in places that are relative contraindications. They may try to convince you (against your better judgment) that Radiesse will be just fine in the lips because they want to attain a large volume correction that will last for long amounts of time. Since this product has a propensity to form nodules in the body of the lip, it is not an injection that should be attempted by most injectors.  Don’t let a patient talk you into injecting this material into the lips unless you are very skilled with this product in this area. When to Consider Novel Treatments Sometimes unusual requests lead to an expansion of therapeutic horizons.  Sometimes they result in a patient who is ecstatic. Occasionally, it results in a patient who is dissatisfied and this is something that we all want to avoid.  When considering a novel cosmetic treatment, consider the individual involved and weigh the relative risks (not only for the patient but for yourself as well) and the potential benefits. I invite you to share your most unusual cases. E-mail me at KenBeer@aol.com. Skin & Aging - ISSN: 1096-0120 - Volume 14 - Issue 03_2006 - March 2006 - Pages: 24 - 25