A 360° Approach to Patient Care in Aesthetic Facial Rejuvenation

Abstract

Background

Aesthetic medicine has traditionally focused on addressing perceived problem areas, with lack of long-term planning and engagement.

Objectives

This article describes a patient-centric model for nonsurgical aesthetic medical practice, termed the 360° approach to facial aesthetic rejuvenation.

Methods

The 360° approach was divided into 4 foundational pillars. Medical literature, the authors’ clinical experiences, and results from patient satisfaction surveys were used to support the approach.

Results

Pillar 1 describes the development of a complete understanding of the patient, based on the use of active listening principles, to characterize the patient's current aesthetic concerns, lifestyle, medical and treatment history, treatment goals, attitude toward aesthetic treatment, and financial resources. Pillar 2 involves conducting a comprehensive facial assessment in contrast to a feature-specific assessment, considering multiple facial tissues and structures and their interrelationships, thus helping to prevent the unanticipated consequences of narrowly focused treatment. Pillar 3 describes leveraging all available treatments and techniques in the development of an initial treatment plan arising from the facial assessment. Pillar 4 adds a time dimension to treatment planning, working toward the goal of a long-term modifiable treatment timeline, with full patient support and involvement; this is designed to facilitate a durable, sustained relationship between the patient and aesthetic healthcare professional (HCP).

Conclusions

Although implementation involves substantial commitment and time, the patient-oriented focus of the 360° approach can help achieve optimal patient outcomes and the development of enduring patient–HCP relationships.

Level of Evidence: 5

Since the arrival of the modern era of aesthetic medicine with the introduction of botulinum toxin for cosmetic indications, practices have frequently utilized a transactional approach to patient care, involving patient-initiated contact to address a specific problem and implementation of a treatment modality recommended by the aesthetic healthcare professional (HCP), which may include dermatologists, plastic surgeons, and other clinicians involved in aesthetic medicine. Alternatively, a patient's self-assessment may result in the selection of an aesthetic HCP based on their ability to provide the preferred treatment. Typically, follow-up is limited to a short period of time; future interactions are left entirely up to the patient, and there is no attempt to fit the treatment approach into a longer-term plan. In this article, we propose an alternate model for patients seeking nonsurgical, aesthetic facial care, termed the 360° approach to facial aesthetic rejuvenation.

METHODS

The 360° approach to facial aesthetic rejuvenation was divided into 4 foundational pillars. The medical literature was analyzed for relevant articles featuring aspects that underpin the 360° approach. Crucial to describing the approach was the authors’ clinical experiences and expertise, which are described in detail in the Results section. Additionally, outcomes from an anonymous patient satisfaction survey, which was conducted between January 2016 and September 2020 as part of Allergan Aesthetics/AbbVie (Dublin, Ireland) business consulting services, were used to support the 360° approach to facial aesthetic rejuvenation. All patients have provided written informed consent for their photographs and data to be published.

RESULTS

The 4 pillars of the 360° approach include understanding the patient as completely as possible, conducting a comprehensive facial assessment to guide the treatment approach, leveraging all available treatments and techniques, and developing, in conjunction with the patient, modifiable long-term treatment plans. Key features of the 360° approach are compared with the transactional approach in Table 1.

Table 1.

Attributes of the Transactional and 360° Approaches to Aesthetic Care

Attribute	Transactional approach	360° Approach
Primary focus	Procedures	Patient
Treatment approach	Focus on putative problem areas only for immediate treatment	Focus on entire face and age-related changes over time
Assessment	Problem area(s) only	Comprehensive facial assessment
Treatment duration	Single treatment; one-off with limited follow-up	Ideally, lifelong with extensive planning

Pillar 1: Understand Your Patient Completely

This pillar is the foundation of the entire 360° approach: a deep understanding of the patient is an absolute prerequisite in facilitating effective assessment and implementing long-term treatment plans. Understanding the patient at this level mandates the improvement of a frequently underdeveloped skill, active listening.

Importantly, patients and aesthetic HCPs often evaluate the overall quality of the treatment experience differently.^1,2 While aesthetic HCPs focus on the technical quality of a procedure (whether it was performed correctly and in accordance with established standards), patients, in contrast, focus on the surrounding relationship (ie, the time spent in consultation and in explaining the procedure, the compassion exhibited by the provider and practice, and the functional quality of the experience). These components are key drivers of trust in the aesthetic HCP, which is the most important determinant of overall patient satisfaction.² To maximize patient satisfaction and retention, aesthetic medicine providers must pay close attention both to the relationship quality and the technical quality that their practice provides.¹

The ability to listen effectively is the foundation of the patient–aesthetic HCP relationship. The need for improved aesthetic HCP listening skills was highlighted in a 1999 study showing that patients were allowed to complete their initial statement of concern before being interrupted or redirected in only 28% of family practitioner consultations; the average time before interruption was 23.1 s.³ A similar study found that the patient's agenda was elicited in only 36% of medical encounters (tellingly, the percentage was higher in primary care [49%] than in specialist visits [20%]); patients were interrupted in 67% of the encounters in which the agenda was elicited, with a median time to interruption of 11 s.⁴ In a study of aesthetic medicine consultations, patients’ overall satisfaction with the aesthetic HCP was far more heavily influenced by how well the aesthetic HCP listened than by their ability to explain treatment options or to answer questions well (Data on file, AbbVie, Irvine, CA; Figure 1).

Figure 1.

Quality of aesthetic medicine consultations: results of a patient satisfaction survey (covering ∼9900 surveys; data on file, AbbVie). (A) Overall satisfaction vs “How well the provider answered questions.” (B) Overall satisfaction vs “How well the provider explained treatment options.” (C) Overall satisfaction vs “How well the provider listened.”

Moreover, a survey of aesthetic care patients undergoing cosmetic injectable treatments identified accurate listening, along with adequate consultation time, as the most important factors in building rapport with the aesthetic HCP.⁵ These factors proved far more important than similar interests and values or a strong interest in the patient's personal or social life.

Active listening describes a set of guiding principles that have proven valuable in improving initial interactions and consultations across a wide spectrum of activities and arenas, including doctor–patient communications, sales, education, leadership, social work, and crisis response.⁶ The principles and benefits of active listening are described below. In addition to these principles, open-ended questions are preferred when possible to encourage the patient to speak freely, and allowing the patient to finish each statement is essential to further reinforce the patient as the central focus.

Principles of Active Listening

Active listening (also known as empathic or reflected listening) describes a set of listening principles intended to improve a speaker's sense that they have truly been heard. Various active listening models have emerged; however, they share 3 basic tenets:

• Express interest in the speaker's intended message through nonverbal messaging: this may involve an open and welcoming posture, leaning forward, making eye contact, and generally indicating interest in the spoken message.

• Paraphrase the speaker's message and refrain from judgment: this both reinforces the listener's understanding of the speaker's message and provides an opportunity to correct any misunderstandings.

• Ask questions to clarify the speaker's message and to encourage further elaboration: this confirms the listener's understanding of the speaker's intended message and allows additional opportunity to reinforce that message.

Extensive research has demonstrated the value of active listening, especially during first interactions. After initial interactions with effective listeners, speakers believe them to be more trustworthy, friendly, and socially attractive than ineffective listeners. Other positive features attributed to effective listeners include attentiveness, responsiveness, and the ability to effectively manage conversation flow. The ability of active listening to generate positive first impressions provides an excellent foundation for long-term relationships based on trust and empathy.

Translating the principles of active listening into the aesthetic consultation begins with a comfortable, uncluttered space adequate for a 1-on-1 conversation, without external interruptions. Sufficient, uninterrupted time is important⁵ for an initial consultation,⁷ and a minimum of 45 to 60 min should be provided (this may be split between the principal aesthetic HCP and other team members). The aesthetic HCP and other team members should be seated during the consultation; research shows that patient perceptions of quality time spent and the provider's ability to listen and convey easy-to-understand information are significantly improved when the aesthetic HCP is seated rather than standing.⁸ In addition, the aesthetic HCP's body language/nonverbal communication should convey rapport and interest in the patient and the topics under discussion.

The initial consultation should be a conversation proceeding through several phases (Table 2) that allow for flexibility and follow the patient's lead. The aesthetic HCP should address the patient's history and reason(s) for making contact, and elucidate underlying motivations, potential red flags, and financial or other limitations⁹; obtaining fully informed consent (procedural, treatment of potential complications, and financial) is essential. The aesthetic HCP should be especially attuned to the patient's cultural/ethnic/religious factors, lifestyle choices, or emotional issues that may influence their views on beauty, aesthetic treatment goals, or aesthetic treatment itself.¹⁰

Table 2.

Structuring the Initial Consultation

Phase	Activities/goals	Implementation
I. Open-ended questions	Use open-ended questions to help reveal the patient's reasons for seeking treatment, goals of treatment, and feelings about aesthetic treatment	Sample questions (use your own wording/phrasing): “Why have you come to see me?” “What can I do to help you?” “What are your feelings about the aging process?” “How do you feel about aesthetic treatment?” For returning patients: “How do you feel about your most recent treatment?” “Compared with your most recent visit, how are you feeling now?” Important to address: “Why now?” (may help reveal underlying motivations)
II. Directed questions	Follow up on patient's answers to open-ended questions to clarify motivations, expectations, financial limitations, and (possibly) unrealistic views and/or expectations	Rephrase/restate the patient's expressed concerns; this reinforces the aesthetic healthcare professional's interest and helps clarify any misunderstandings or unrealistic expectations Sample questions: “Why is this aspect so important to you?” “If we could ____, how would this help you?” It is typical to cycle several times between open-ended and directed questions, as issues raised during the initial phase are addressed sequentially
III. Conclusions and suggested approaches	Present the patient with treatment options, while restating patient's concerns Summarize the way(s) those options address the stated concerns, as well as any additional benefits and treatment risks	Allow sufficient time for the patient to raise questions about the proposed course(s) of action, and for the aesthetic healthcare professional to answer in language the patient will understand Final framing question: “How do you feel about our proposed course of action?”; this helps reinforce the collaborative and long-term nature of the patient/aesthetic healthcare professional relationship, and secure a firm buy-in from the patient

Troubleshooting: If a patient hesitates or declines treatment, it should be viewed as an opportunity to revisit, using open-ended questions, issues, or concerns that might have been missed initially. Frequent hesitation or declined treatment may be a signal that the consultation has been inadequate, and should lead to a review of and, as appropriate, improvements/modifications in consultation technique.

Ideally, the initial consultation should become the starting point for a long-term relationship, based on the development of trust, which is ultimately the foundation for an enduring relationship.⁹ A key cornerstone in building trust is logic or cognitive ability, which most aesthetic patients evaluate based on qualifications, training, and experience, viewing these as the most important factors in building trust.⁵

The other cornerstones of building trust are authenticity and empathy.⁵ Authenticity is best established using the principles of active listening, conveying the patient as the primary focus, and full engagement of the aesthetic HCP. Empathy, the human capacity to connect with others emotionally, cognitively, and perceptually, and to relate those aspects of others’ lives to our own,¹¹ is often thought of as an inborn capacity¹¹; however, empathy is teachable, and one's capacity for empathy may be improved. Improved empathy (both self- and other-directed) among aesthetic HCPs translates into improved patient satisfaction, treatment adherence, and outcomes.¹¹

Pillar 2: Conduct a Comprehensive and Holistic Facial Assessment

A comprehensive full facial assessment, the foundation for treatment planning and decision-making in aesthetic care, should be a requisite part of the initial consultation regardless of the presenting complaint. It proceeds in 2 stages, beginning with an evaluation of the patient's facial features and their interrelationships from a global perspective (as opposed to focusing on individual features/elements), before moving to consideration of the relative contributions of individual facial tissues/structures to the overall appearance. This holistic perspective, combined with the aesthetic HCP's knowledge of facial anatomy and function, ethnic and gender considerations, and the typical course of age-related changes in facial layers and tissues,¹² facilitates development of individualized treatment plans that result in greater patient satisfaction.

The differences between partial assessment and comprehensive facial assessment are analogous to those between transactional and 360° approaches. Whereas partial assessment focuses only on the putative problem area identified by the patient, comprehensive assessment considers the identified problem area in the context of the full face, including multiple views (frontal, lateral, oblique), the effects of light and shadow, and dynamic effects resulting from actions such as speaking, smiling, or eating.

The principles of comprehensive full facial assessment are based on the realization that the close association of facial anatomic structures, coupled with muscular movements and age-related changes, can lead a regional problem (eg, midface volume loss) to affect multiple adjacent regions (sagging/wrinkling throughout face).^13,14 Regiospecific treatment based only on partial assessment may appear successful from a straight-on view, but may alter facial shape/contours, leading to dysmorphisms. A common example is a patient seeking lip augmentation; comprehensive assessment not uncommonly reveals maxillary retrusion and pyriform fossa recession, leading to elongation of the ergotrid and reduction in the vermilion lip. Treating the perceived volume reduction alone is unlikely to fully address the problem; in contrast, the integrated approach embodied in a complete facial assessment helps develop a more global treatment solution, in turn improving aesthetic results.¹³

A key advantage of comprehensive facial assessment is that it provides a picture consistent with how others perceive one's face, rather than solely how we perceive our own. Our visual self-image is primarily a product of the view in the mirror, and often has an exaggerated focus on perceived problem areas rather than the whole (Figure 2).

Figure 2.

How putative facial problem areas are perceived by ourselves (left) and others (right).

Research shows that all aspects of facial imaging, including detection, discrimination, and recognition, are processed holistically, rather than in parts.¹⁵ Within 0.1 s, and with no obvious conscious effort, humans not only routinely recognize faces, but also form impressions regarding important interpersonal parameters (eg, attractiveness, likeability, trustworthiness, aggressiveness).¹⁶ These findings strongly suggest that treatment plans based on comprehensive, holistic facial assessment are more likely to produce results that are aesthetically pleasing, especially to others, than those based on partial assessment.

Conducting a comprehensive facial assessment begins by asking the patient's permission. The ultimate goal is to secure the patient's full endorsement by describing the process, and then making the explicit link between the initial complaint and the ability of the comprehensive assessment, in contrast to a complaint-driven assessment, to facilitate optimal treatment planning and outcomes. This helps reinforce the collaborative nature of the 360° approach, further establishing the patient and the aesthetic HCP as partners. Questions or objections may be addressed by emphasizing the ability to assess pretreatment status and postprocedure changes from multiple views and with varying light and shadow, and to provide more positive outcomes with a balanced look. Table 3 summarizes the individual components of a comprehensive facial assessment, which include evaluations of facial shape, dynamic effects, symmetry and balance, and effects of light and shadow. These concepts are further illustrated in Figure 3.

Table 3.

Conducting a Complete Facial Assessment

Activity	Implementation
Assess facial shape	Shape can be distinguished from surface features by constructing an imaginary silhouette of the patient's face Shape assessment identifies areas to be restored in aging patients and those that may be enhanced in younger patients17 For an example, please refer to Figure 3A
Evaluate dynamic effects	While conducting the shape assessment, evaluate dynamic effects by asking the patient to smile, talk, and show various expressions Dynamic assessment reveals previously unseen aspects of facial tissues and structure, which is particularly important for planning treatment with fillers This concept is further illustrated in Figure 3B
Assess symmetry and balance	Dividing the facial image into horizontal thirds and vertical fifths helps to evaluate facial symmetry and balance18 This concept is further illustrated in Figure 3C
Assess light and shadow effects	Photographs using overhead lighting at several angles can be useful in assessing the effects of light and shadow on perceived facial contours It may be helpful to render photographs in grayscale to emphasize the shadowed and illuminated areas

Figure 3.

(A) Facial shape assessments. (B) Evaluating dynamic effects. (C) Assessing symmetry and balance. The patient shown in B and C is a female who was 43 years of age at the time of treatment.

A clinical-grade photographic setup is an essential tool for comprehensive assessment, interpretation of assessment findings, treatment planning, and charting clinical course. The setup should provide multiple views, a range of exposure/lighting conditions, and precise patient positioning; the key is to develop a reproducible, standardized protocol (typically involving 6-12 photographs) for each patient, facilitating comparisons over time. Photographs can help the aesthetic HCP describe findings and the effects of proposed treatments; many patients will see features in a photograph that they do not readily perceive in the mirror. For patients who struggle with self-perception/self-identity issues, photographs can be an objective inanimate layer that provides emotional distance.¹⁹

In sharing assessment findings with the patient, an initial focus on positive features helps set the tone. The aesthetic HCP may begin by describing first impressions upon meeting the patient, and the nonverbal messages being transmitted by the patient's face. The consultation may then transition to the specific findings of the assessment, beginning with facial contours and features that might be considered for treatment. Dynamic and light/shadow findings may be presented in the context of their impact on treatment approach. Some patients may also find that a deeper understanding of age-related changes helps them select appropriate treatment approaches.

When several targets for treatment are under consideration, the discussion of treatment sequencing (including treatment of the original patient-identified problem area, if any) should be guided by the areas with the greatest impact (ie, potential for the most-positive outcomes) first. For many patients, treatment in the midface is likely to have the greatest immediate impact on the patient's overall look and first impressions, because the eyes automatically target that region upon encounter.²⁰ Once there is a general agreement on the treatment course, the aesthetic HCP should review with the patient the target areas and proposed treatment(s), anticipated results, and how the proposed treatment sequence should deliver these benefits as quickly as possible.

The facial assessment approach described here clearly requires substantially greater time, at each stage of the patient interaction, than customary in a less-comprehensive approach. However, this time should be considered an initial investment, with long-term rewards in the form of patient satisfaction, long-term patient engagement, and the extended viability of the practice.

Pillar 3: Leverage All Appropriate Treatments and Techniques

Pillar 3 represents the translation of knowledge gained during the patient-focused consultation and assessment into the development of a patient-centric treatment plan. The number of tools and procedures for facial treatment has increased dramatically over the past 25 years, including new topical formulations, directed-energy treatments, resurfacing techniques, injectables, and surgical techniques.^21,22

The wide range of available treatments, each with a distinct target, reflects the complex, multifactorial nature of facial aesthetics and aging^12,14 and represents the more holistic vision of aesthetic medicine embodied in the 360° approach. It also provides the ability to combine different approaches, as no single technique is designed to address all layers and drivers that influence aging and thus cannot fully resolve most treatment-worthy issues. Studies of aesthetic practices have demonstrated that combination treatment produces greater patient satisfaction than monotherapy. In a study by the FLAME Group involving 2604 patients across 5 continents, patients received 12 months of monotherapy with either hyaluronic acid (HA) fillers or neuromodulators, or combination therapy with both. Patient retention rates at 1, 3, and 5 years (used in this study as a marker for patient satisfaction) were significantly higher in the combination group than in either of the monotherapy groups (at 5 years: combination, 65.6%; neuromodulator alone, 39.0%; HA alone, 40.3%; P < .0001 for each monotherapy vs combination).²³ Another multinational study showed not only that triple-combination treatment (neuromodulator + filler + energy-based complexion treatment) was preferred over monotherapy, but also that combination treatment received in a single day was preferred over sequential treatments. Patients (n = 509) received neuromodulator monotherapy (n = 300), same-day combination treatment (n = 116), or sequential combination treatment (n = 93) over 12 months. Cumulative retention rates, reflecting visit frequency, were significantly below baseline for both monotherapy and sequential combination treatment (−19.5% [P < .001] and −14.1% [P = .046], respectively), but were significantly above baseline for same-day combination treatment (52.4%, P < .001).²⁴

Table 4 summarizes the development of a treatment plan, including the selection of treatment modality, consideration of combination treatments, and sequencing of treatments. Guiding principles include prioritization of the patient's initial expressed concern or complaint; balancing treatments with an immediate cosmetic effect (eg, neuromodulators and skin treatments) and those addressing underlying causes (eg, fillers); and providing a clear picture of anticipated outcomes and costs.^14,19

Table 4.

Developing a Treatment Plan¹⁴

Planning activity	Implementation
Selecting treatment modality	A comprehensive assessment is the foundation of an effective treatment plan; this should include full consideration of underlying drivers for specific problems (eg, the multifactorial nature of jowl formation) Treatment selection should flow naturally from the assessment; as for any given problem, there is usually a small number of reasonable treatment options Beyond its basic appropriateness to the problem at hand, the selection should reflect the greatest potential benefit and lowest risk of tolerability issues
Treatment sequencing	At the outset, treatment selection should address the patient's primary concern (even if through indirect effects) For example, a patient with insufficient lip fullness as the primary complaint may see sufficient benefit from fillers used in nearby facial regions Initiating treatment in the midface region typically provides the most noticeable benefits quickly20,25 In most cases, treatment sequence is extremely flexible, and absent other factors, should be determined based on patient availability, preferences, and anticipated downtime If possible, alternate treatment modalities from visit to visit, balancing those with short- and long-term impacts
Consider combination treatments	Combination treatments (especially if delivered at the same session) appear to generate improved patient satisfaction compared with monotherapy If possible, combine treatments that provide short- and long-term benefits

In presenting the plan to the patient, the results of the comprehensive assessment should first be reviewed in the context of the issues or concerns initially raised by the patient, which may be framed in terms of their relationships to the patient's history, and genetic and developmental background, as well as the overall aging process. The typical course of facial aging may then be described (using language appropriate to the patient) as reflective of changes in facial tissues that proceed in an inside-out direction (ie, bone, muscle, fat, and skin).¹² Broaching the topic of age-related changes introduces aesthetic care as a lifelong relationship encompassing both treatment and prevention, emphasizing well-planned and well-executed aesthetic management as a method to ensure graceful aging with a natural, balanced look. It should be stressed that the effects of treatment can extend well beyond the face in the mirror, and are likely to impact interpersonal relationships as well; observers who were shown patient photographs following noninvasive panfacial treatments associated them with more positive character traits and social skills than pretreatment photographs of the same patients.²⁶ Moreover, the expression of positive emotions has been linked with improved mood²⁷ and may even predict more positive life outcomes.²⁸

The initial treatment plan may then be presented, explaining (in language appropriate for the patient) the rationale for and anticipated outcome of each step, session, or treatment modality, along with its anticipated costs in terms of time and expenditures. It is also appropriate to discuss how a 12-month plan (a common planning horizon) may be reassessed and modified over shorter and longer terms. The patient's reaction to the plan should then be solicited in a manner that welcomes questions or concerns.

Financial and/or time constraints are the most frequent patient concerns about moving forward with the proposed plan. Financial limitations are extremely common, given the broad absence of insurance coverage in aesthetic medicine. Several approaches may be (jointly) considered in search of solutions; if essential vs desirable treatments can be easily distinguished (in terms of anticipated outcomes), the essential treatments can be prioritized.

Treatments that can be divided into multiple sessions, such as filler injections, could be spaced out over a longer period; this also generates more gradual change, which may please some patients. These split treatments can also be alternated with treatments that provide a more immediate cosmetic effect (eg, neuromodulators and skin treatments). However, it is important to establish that the costs of a multistep treatment can be fully covered before commencing treatment; partial treatment is likely to leave both the patient and the aesthetic HCP dissatisfied with the results (and the patient feeling that the process was not worthwhile).¹⁹

Time constraints are usually less onerous than financial ones, but typically involve aligning patient availability with practitioner or equipment availability, as well as the patient's tolerance for postprocedure downtime. In most cases, time issues can be resolved by extending treatments over a longer time, or by combining treatments in a single visit; as noted above, combination treatment sessions have been well received by patients.²⁴

It is a common scenario in aesthetic practices to encounter patients seeking a specific treatment for a perceived problem (typically self-diagnosed) that is inappropriate or unlikely to produce the desired benefits. For the aesthetic HCP, this should trigger an exploration of the reasons the patient has selected the particular treatment and a conversation with the patient about various options and likely outcomes. If there is obvious risk involved, invoke the Hippocratic Oath injunction against doing harm; the conversation can be positioned as a benefit vs risk comparison.²⁹

Requests for inappropriate or unnecessary treatments frequently arise from an underlying psychiatric condition, such as body dysmorphic disorder (BDD).³⁰ It is important for aesthetic HCPs to understand that patients with BDD will not benefit from aesthetic care; comprehensive screening is recommended to ensure patients with BDD are identified and referred for psychiatric treatment.³⁰

The broad and rapidly growing range of available noninvasive and invasive treatments has confronted aesthetic medicine practices with the challenge of staying current with new treatment options and evolving developments regarding existing options, such as method refinements, new safety signals, and data on patient satisfaction. Larger practices often include practitioners with focused expertise in one or a few treatment options, with experts across the full complement of existing treatments. In these practices, staying abreast of current developments (according to each practitioner's interest and expertise) should help ensure quality input on new information across the entire range of treatment options.

The decision to add a new treatment option or competency to a practice must be carefully considered and based on the totality of available clinical data (including large studies with relevant efficacy and safety results) and scientific justification to support its use; in addition, the anticipated need for the treatment in the specific practice, based on its patient population, should be assessed. The safety, tolerability, and efficacy results on which market approval was based should be carefully reviewed; these should include a wide range of patients and skin types and be relevant to the issue at hand. This should be followed by a review of postmarketing safety data (including any new safety signals), efficacy issues, and any issues affecting specific patient groups.

Any available information on patient interest in or acceptance of the new treatment modality, as well as actual user experiences, should be actively solicited; in many cases, colleagues’ experiences, perceptions, and insights, as well as their descriptions of patient experiences, can guide the decision to add a new treatment/competency. Once a new treatment capability is added, the practice or individual practitioner should ensure that a comprehensive statement of that treatment's benefits and risks is developed and presented in full to all patients considering it.

Pillar 4: Develop Modifiable Long-term Treatment Plans

In Pillar 4, the time component is added to the assessment and development of treatment plans; the longitudinal component of treatment planning further distinguishes the 360° approach from traditional approaches. Planning over the long term facilitates a proactive approach to the prevention or amelioration of future issues, instead of a reactive approach to existing ones. This proactive approach is essential to aging gracefully with a natural, balanced look, and ideally may take the form of a collaborative journey as the patient and aesthetic HCP age together.

The focus of the 360° approach is the unique needs of the individual patient; however, it can be helpful to realize that many aesthetic care patients fall into one of several archetypes. These archetypes are intended only to help guide the initial consultation and subsequent patient interactions, and not replace them. Instead, they may help aesthetic HCPs better understand their patients’ motivating factors and goals, while exploring the patient's unique attributes and needs.³¹

Younger Patients

Young patients are typically heavily influenced by social media, and frequently express a desire for a specific look, or to look like a specific celebrity. Those exploring aesthetic care often seek treatment early in life, and are generally accepting of aesthetic treatment; they are often less loyal to brands than to the treatment experience itself. The key to long-term satisfaction is to employ active and authentic listening in a collaborative relationship that can help flag and address unrealistic expectations (eg, seeking an angular look for a round face) and ensure that treatment goals are based not on an image or filter but instead on developing their own desired outcomes. A conservative approach to treatment is recommended, enabling the patient to experience the procedures and effects of fillers and skin treatments without major changes in overall look. Building the patient's confidence in this way helps pave the way for regularly scheduled aesthetic consultations and treatments over the long term.^31,32

Positive Aging Patients

These patients, usually in their forties and older, are primarily motivated by the desire to reverse the signs of facial aging, including its effects on the overall look (eg, sad, tired, angry, or worn down), in part to minimize the mismatch between their self-image and what they see in the mirror. Most are leery of dramatic changes; however, they typically appreciate long-term treatment as a positive approach to minimizing the development and progression of aging symptoms. Initiating minimal treatment (eg, with fillers, skin treatment, neuromodulators) helps to build the patient's trust, facilitating long-term planning and treatment (including more-invasive treatment if appropriate).³¹

Cosmetically Motivated Patients

The primary concern for these patients is a short-term fix for a perceived flaw or feature; they often express a specific need (eg, “I want fuller lips” and “I need to get rid of these wrinkles”) at the outset of the consultation. In most cases, they are unaware of the possible corollary effects of the requested procedure on neighboring facial regions and their overall look. The aesthetic HCP should be empathetic to the initial request and should use their clinical expertise to explore the emotional drivers and patient perceptions to better understand the specific request and desired outcome. In most cases, a comprehensive facial assessment should be recommended (Pillar 2), which resets the consultation and lays the groundwork for a holistic treatment plan.^31,33

Regardless of archetype (if any fit), most patients make first contact with an aesthetic medicine practice while still in a transactional or problem area mindset; therefore, the concept of longitudinal planning should be introduced gradually. The initial step is to solicit the patient to speak freely and comprehensively about their goals and needs. Then, the patient may be asked whether they would like to hear how aging affects the face and overall appearance; most patients approve, and their approval is the first step toward a longer-term outlook and mindset about aesthetic care.

A thorough review of the progression of age-related structural changes should pave the way for discussion of ongoing treatment over the long term; the steps involved in the development of a long-term treatment plan are summarized in Table 5. The completely personalized nature of a long-term plan should be emphasized to the patient, as well as its ability to match the gradual pace of age-related changes with gradual, incremental correction of specific concerns. Equally important, reassessment should be stressed as an ongoing process, with the resulting ability to modify long-term plans as required to achieve the patient's goals.

Table 5.

Long-term Treatment Planning

Planning activity	Implementation
Gather all necessary information19,21	The critical information to be gathered includes that obtained during patient consultations as well as the complete facial assessment Additional questions should be asked in the context of long-term planning, including:  “What can I do to help you?”  “Tell me about your personal philosophy on aging?”  “Tell me about your lifestyle?”  “What are your treatment preferences?”  “How often can you visit the clinic?”  “What kind of downtime does your lifestyle permit?”  “What is your comfort level when it comes to investing in your treatment plan?”  “What are your financial constraints?”
Outline the optimal treatment plan	The plan should begin with early resolution of the patient's primary complaint(s), even if indirect Outline the plan by matching treatment needs with recommended treatment(s), based on aesthetic healthcare professional expertise Combination treatments should be proposed when appropriate Consider interweaving treatment modalities over time (eg, injectables/fillers interweaved with topical treatments) The anticipated budget for the proposed plan should be the final part presented The initial proposed plan should accommodate the patient's expressed needs in terms of treatment preferences and lifestyle/time constraints; however, it should not be developed to work around financial ones These are best accommodated based on patient feedback to the initial proposed plan
Ensure that the patient understands the proposed plan	Make sure the proposed treatments are fully described to the patient (especially those the patient has not yet encountered) Emphasize how the plan is flexible and can be modified over time It should be as specific as possible regarding short-term goals and proposed treatments, but less so and amenable to modification in the longer term Ask the patient questions to confirm their complete understanding
Allow the patient to choose and prioritize	Encourage patient feedback to the proposed plan, and reinforce the collaborative nature of your therapeutic relationship Address financial constraints: Possible solutions include reducing the frequency of visits/treatments, selecting partial treatments, or changing the order of treatment If partial treatment is considered, make sure the patient understands potential consequences of partial treatment ◦ This is especially important with fillers, with which partial treatment may result in unsatisfactory results and substantial expenditures Be as supportive as possible regarding financial constraints, and be prepared to offer solutions, when feasible
Revise the treatment plan as appropriate	Revise the plan based on agreed-upon solutions and answers to patient questions/concerns Secure patient approval of the revised plan; modify as appropriate until agreement is reached Reinforce the ongoing nature of the review and revision process with the patient Periodic review of the treatment plan should be scheduled on a regular basis (eg, once yearly)

When introduced and carried out properly, long-term treatment planning is likely to be recognized by patients as an important psychological component of aging well.^6,19 Moreover, by encompassing active listening, long-term planning facilitates a closer relationship between the aesthetic HCP and patient, increasing trust in each other's judgment and decisions, as well as the patient's openness about their goals. The effects of this pillar of the 360° approach extend beyond improving the patient's appearance, helping the patient feel empowered as they and the aesthetic HCP age together. The clinical trial data associated with this article can be requested online by qualified researchers through Vivli (Burlington, MA) following review and approval of a research proposal, statistical analysis plan, and execution of a data sharing agreement. The data will be accessible for 12 months.

DISCUSSION

The 360° approach provides a framework for a holistic model of nonsurgical aesthetic care, involving patient-centered longitudinal assessment, planning, and treatment. It is evident that adopting this model requires a great deal of active planning and commitment from practice leaders, and ultimately, from the entire staff. However, the initial step is recognizing the potential in this approach and paving the way for the evolution of the practice toward this ideal. Genuine aesthetic expertise is rooted in the ability to create a positive impact in patients’ lives; by continuously supporting them throughout their treatment journeys, they can feel confident and empowered in their appearance throughout their lives.

This qualitative article has several limitations, including limited in-depth quantitative and comparative data to distinguish it from other approaches to facial rejuvenation, such as the transactional approach. Future studies may quantify improvements to overall patient experiences and satisfaction, patient retention rates in clinical practice, or conversion rates from nonsurgical to surgical patients using this approach compared with the transactional approach. Additional case and real-world studies may also evaluate the implementation of the 360° approach in dermatologic and surgical practices to determine its suitability for different patient populations.

CONCLUSIONS

The 360° approach with its 4 foundational pillars provides a comprehensive, holistic, and patient-centered approach to aesthetic facial rejuvenation. This approach can help achieve optimal patient outcomes and satisfaction, as well as the development of enduring, potentially lifelong patient–HCP relationships, which are crucial for long-term practice viability.

Disclosures

Dr Humphrey is a consultant, speaker, and investigator for Allergan Aesthetics, an AbbVie Company. Dr Bertucci is a speaker, consultant, and/or investigator for Allergan Aesthetics (an AbbVie Company), Evolus (Newport Beach, CA), Galderma (Lausanne, Switzerland), Medytox (Seoul, South Korea), Merz (Frankfurt, Germany), Prollenium (Richmond Hill, ON, Canada), Revance (Nashville, TN), and Teoxane (Geneva, Switzerland). Dr Heydenrych is a speaker and consultant for Allergan Aesthetics (an AbbVie Company), Galderma, SkinCeuticals (New York, NY), and Genop Healthcare (Carlswald, Midrand, South Africa). Dr Ogilvie is a consultant, speaker, and principal investigator for Allergan Aesthetics (an AbbVie Company), Evolus, Galderma, Merz, Medytox, and Revance. Dr Safa is a consultant for Allergan Aesthetics (an AbbVie Company). Dr de la Guardia is a full-time employee of AbbVie (Madrid, Spain).

Funding

Allergan Aesthetics, an AbbVie Company (Dublin, Ireland), funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship.