Panel Debates Best Way to Handle Cosmetic Complications

PHOENIX — Cosmetic dermatology procedures require patient education and thorough consent, a panel of four physicians agreed during a discussion of how best to manage any complications that do occur.

Among the questions that were discussed: Do you give a patient a refund if a complication occurs? Do you charge an unhappy patient for a touch-up? When does a complication with hyaluronic acid warrant reversal with hyaluronidase? Also, is it necessary to get informed consent each time an established patient comes in for a series of treatments?

Dr. Ken K. Lee posed these and other questions as he moderated this session at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If a bruise occurs under the eye, for example, do you give a refund or offer free services? asked Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

"Bruises do occur. It's in the informed consent; that is the beauty of the multiple consent form," said Dr. Timothy Flynn, who is in private practice in Cary, N.C. Be compassionate and discuss strategies to avoid bruising the next time, he said. "But, no, I would not give a refund—it is within the expected risks."

"I would not give a refund either," said Dr. Joel L. Cohen, a dermatologist in Englewood, Colo. But, "I might see if they can meet with someone in my office about makeup, at no charge."

Dr. Dee Anna Glaser agreed. "I do pulsed dye laser if they are very upset about this, at no charge. But we don't give refunds." Dr. Glaser is a professor of dermatology at St. Louis University.

Dr. Lee asked the panel for advice when a cosmetic patient presents with a bluish tinge or a Tyndall effect from a more diffuse nodule in their tear trough 1 month after hyaluronic acid injection.

Calculate how much hyaluronic acid was injected, and use hyaluronidase to reverse the effect, Dr. Flynn suggested.

"Tell the patient you are going to melt it away. You have to warn them you are going to melt most of the hyaluronic acid in their face" as well, he said.

"I rarely use hyaluronidase," said Dr. Roberta D. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif., and St. Louis. "If you use the hyaluronidase, you will really erase their correction." Instead, she discusses camouflage and other options with the patient.

Dr. Lee also asked about treating a woman with "rock hard nodules" under her eyes, for example, 1 year after poly-

Dr. Sengelmann said she would do a biopsy. Dr. Glaser said 1 year is unusually long for such a complication to arise—most develop within the first few months post treatment.

Dr. Sengelmann asked the panel if they charge for hyaluronidase if a patient is referred for a Tyndall effect complication. "I don't charge for the hyaluronidase … or charge them anything extra," Dr. Flynn said. "I kind of feel bad for these people."

"If it's my complication, I do not charge them," Dr. Cohen said. "If it's someone else's patient … I do." He estimated that hyaluronidase costs about $50 for a single-use vial. "There is a risk of anaphylaxis. You need to get their consent," he added.

Dr. Lee next asked the panel if they typically charge when outcomes do not meet their own or the patient's expectations.

"If the problem was not enough volume, we charge for whatever we use in terms of filler," Dr. Flynn said. "Toxins are sometimes different. With an unhappy patient, I can treat with more toxin at no charge."

One challenge is when a patient is willing or able to pay for only a small amount of product but wants a full effect. Dr. Cohen suggested handing a mirror to a one-syringe patient. "Ask them at that point if they want an additional syringe now or later," he said. "Sometimes if I look at a patient a few weeks later and I see I could have done better, I give them a little more at no charge."

Dr. Glaser also offered a strategy with botulinum toxin. "Sometimes when I am really trying to get the patient to use a little more toxin and they are reluctant, I tell them I will do the next 5 U for free this time and if they like the result, they will pay next time."

Dr. Sengelmann typically asks her new patients to return 2–3 weeks after an initial treatment to address any concerns. "If I feel I did not achieve a result, I will give them 5 U, sometimes 10. That is a great way to build rapport with patients."