Editorial Board Forum: Do Patients' Fat Reduction Expectations Vary by Specialty?

MILES GRAIVIER, MD: DO YOU THINK THAT THERE ARE DIFFERENT PATIENT EXPECTATIONS REGARDING FAT REDUCTION DEVICES BASED ON THE TYPE OF PRACTICE YOU HAVE? KNOWING THAT A PRACTICE OFFERS A MORE INVASIVE LIPOSUCTION OPTION, FOR EXAMPLE, ARE PATIENTS MORE DEMANDING THAT THEIR EXPECTATIONS (EVEN UNREASONABLE ONES) ARE MET?

Gregory Buford, MD: I absolutely think that we as plastic surgeons are held to a little different standard with respect to outcomes with these devices because our patients expect a more dramatic response. They are used to us performing surgery and are used to surgical results...not the results we are seeing with the non-invasive modalities. To this end, I think we have to be even more cautious and comprehensive when discussing expectations with our clients.

Paul Carniol, MD: I believe that patient expectations vary between physicians. This can relate to the physician's specialty as well as the patient's perceived practice profile.

Candid discussions with patients before a procedure can often help to avoid this type of communication breakdown but even with these discussions patients still may have unrealistic expectations.

Realistic before-and-after photographs are often helpful.

Brian Beisman, MD: When considering non-invasive body contouring devices, as with any other new drug or device, I believe it is extremely important to use an evidence-based approach. Of the technologies available, there is far more in the way of actual clinical trial data for the Zeltiq device than for any other. We know that this device reliably and reproducibly produces an average 20 percent or so reduction in fat layer thickness. This has been demonstrated in numerous trials. There is limited trial data on most of the other devices although some have more than others.

I have personal experience with numerous RF devices, the Zeltiq device, and some other devices that use low level light, combination approaches, etc. In my practice I ultimately use the Zeltiq CoolSculpting. I do not have experience with Vanquish.

I do feel that published or podium statements about devices should be made in the context of available clinical trial data or else specified as anecdotal experience.

Jeanine Downie, MD: Vanquish is a multipolar radio frequency device and has the largest spot size available. It is a breakthrough in terms of the fact that it treats a larger area than any other fat melting machine so it can reduce greater areas of fat rapidly.

Many practices use the Vanquish to globally reduce larger areas of fat before fine tuning with the Zeltiq or Exilis. It absolutely does cause apoptosis, which is critical— you must destroy the fat cells (or remove them) for a long-term effect.

Dr. Beisman: Whichever device is used, there is an art to non-invasive body contouring. Patient selection, education, treatment technique, and a host of other factors are all important elements. I feel that some of the unreasonable expectations sometimes are generated by anecdotal (or frankly incorrect) information as opposed to information that reflects trial data.

Granted, trials tend to be industry-sponsored and thus it can be argued that they are inherently biased but at least the number of subjects treated, the methods used to evaluate outcomes, etc. are made known and can be assessed by the physicians offering the services. I believe this standard should be observed whether we are discussing skin tightening, skin resurfacing, body contouring, home use devices, etc.

Joe Niamtu,III, DMD: I have always felt that surgical practices attract patients with higher expectations and expect a bigger bang for their buck. The clientele is different from non-surgical practices where small changes are more accepted and are the norm.

If my patients can't see a difference in a before-and-after picture, they are unhappy. A patient at a minimally invasive office may be happy with a slight improvement in lower lid wrinkles whereas if they had a bleph and had the same level of residual wrinkling they would want their money back.

The other side of that equation is that I think it is harder for surgeons to promote some of the devices and therapies that do less because in their heart, they know that the result will be small and may not satisfy the patient. I see a lot of surgeons turf this stuff to their aesthetician to provide distance just for this reason.

Heidi Waldorf, MD: I would disagree with the notion that plastic surgeons are held to different outcomes than dermatologists because they do surgery and patients expect a more dramatic response. In fact, I would suggest it is the opposite: Because patients in surgical offices have the option of a surgical or invasive treatment— whether it is a facelift, tummy tuck, or liposuction (noting of course that many dermatolgists do lipo; I am just not one of them)—the non-invasive device option is not generally presented as an alternative to surgery but rather as an adjunct, maintenance therapy, or just a spa treatment. Since it is done in a separate area that is not an OR, the patient knows it is not an equivalent.

In a derm office however, the patient presents because he or she wants to avoid surgery. Our patients often come in with particularly unrealistic expectations thinking that the ‘non-surgical facelift' or ‘liquid lift' or ‘non-surgical lipo,' as they are often termed by marketers, is indeed an equivalent. It is one of the reasons I refuse to use any language like that. I tell them that lipo is lipo and a facelift is a facelift.

Joel Schlessinger, MD: The other factor to consider here is intrinsic versus extrinsic marketing and how they affect patient expectations. We have often turned down procedures or equipment/lasers from our practice due to the level of false/outlandish expectations that are being spun for it by the company or “friendly physicians” (read “paid consultants”).

Almost every non-invasive laser or modality to date has been blown way out of proportion by the company and reps and had no chance of reputation repair by the clinician by the time it was popularized. The “Oprah Effect” and now the “Dr. Oz Effect” have also inflated and then deflated numerous procedures.

This isn't the fault of one company as much as it is a global difficulty with lasers, in particular. Fat, however, may be a poster child for this happenstance. There is so much misinformation by the companies and now, unethical clinics/medispas/whatevers that it may be out of control and unsalvageable.

The same thing happened to other, decent, treatments and is now happening with this, which is sad. Non-invasive fat treatments have some utility, but the industry is engaging in a game of one-upsmanship that could derail and/or destroy any public faith in these products.

Dr. Buford: Between “Oprah,” “The Doctors,” and the “Dr. Oz” carnival, consumers are being bombarded with results that are outliers and not necessarily attainable for the average patient. And when they do, they come into our offices armed with unrealistic expectations and are doomed to failure from the get go.

Vivian Bucay, MD: The main thing with these devices is the same issue as with other devices: setting expectations. I agree with the comment that patients hear what they want to hear. I show them before and after photos of good results and underwhelming results.

There are the very rare cases of hyperplasia post CoolSculpting, and I have seen one patient in whom this occurred after the first treatment. The recommendation was to do a second treatment, which made the situation worse. Zeltiq's clinical team reviewed the treatments (so document, document, document!) and found that everything was done according to protocol. They assumed responsibility for the unfavorable results and worked with the patient to resolve the matter to his satisfaction. I can't say enough good things about their clinical support team.

Dr. Buford: The other problem that I see is that many of these patients are looking for a quick fix and expect the laser to give them results that will last long-term. But without changes in diet and exercise, we all know that these results are really not permanent and that these patients will simply go back to their pre-treatment state if changes in lifestyle are not being made.

The Experts Say

DR. NIAMTU: We all know that the trick is to be honest with our patients and not overpromote. But…many of them hear what they want. Staying on the cutting edge is good for business, but embracing the bleeding edge and promotion of untested products can hurt a practice when the results don't match the hype. We all have friends who spent $100K on some machine that now functions as a door stop.

DR. BIESMAN: I think there is room for plenty of different technologies in the marketplace as none is perfect by any stretch of the imagination. I advocate a balanced, science-based approach as new drugs and technologies are discussed. I think that approach raises the bar for industry and ultimately will be the best for industry, physicians, and consumers in the long run.

Dr. Bucay: I explain that it may take more than one device to achieve the results patients are seeking when it comes to body shaping. I do a full consultation describing the ideal treatment scenario and all possible costs. I don't do liposuction, but I try to make sure to present this option first. I am happy to refer patients out. The patients I want are the ones who truly don't want surgery or who just need a little bit of “tweaking” to look their best. It's so not worth the headache of dealing with a potentially unhappy patient just to make a few extra bucks.

Patients understand that it may take more than one modality to achieve their goal. It's easy for them to understand that because we have done such a good job explaining a multimodality approach for facial rejuvenation. Most patients understand that BoNTA, fillers, lasers, peels, skin care, and surgical interventions may all play a role in an integrative approach in achieving a more youthful and refreshed appearance. We charge for each of those services, but we can also bundle some of those services.

I do the same with CoolSculpting, Vanquish, and Exilis. I charge differently for Exilis done on its own versus as an add-on post Vanquish or CoolSculpting. CoolSculpting carries disposable costs but doesn't require staff to do the procedure once the patient is hooked up to the device. It also takes an hour per treatment plus around 15 minutes to turn the room around. Vanquish is only 30 minutes and has no disposables but does require a staff member to monitor the treatment. Those 30 minutes can be a plus because staff then has the opportunity to let the patient know about other services. Exilis is hands-on and can be labor intensive for staff to perform, but patients like the idea of skin tightening after fat reduction. Patients who have had lipo come see me all the time seeking a solution for “lumps and bumps.”

Dr. Buford: I think it takes far more than a device to affect permanent change. It takes a change in lifestyle, as well, and that requires the patient to actually participate in their care.

I have begun a more aggressive and comprehensive program now than ever before that combines nutritional counseling to help look deep inside and figure out what is really going on.

I think this will be the way of the future and an approach that will guarantee much more permanent results.

Dr. Waldorf:

Clearly permanent life changes are best. But all the external devices are only appropriate for patients with low BMI, so presumably they are already doing well with diet and exercise (within reason for someone with a busy work/social/family life). Maintaining that lifestyle is part of setting expectations.

I also feel it's important to separate being a dermatologist or plastic surgeon, etc. from deciding to be an ‘anti-aging' specialist. There is nothing wrong with the latter, if you take it seriously and have thorough training or build a team with that training. However, I'm a dermatologist, not a nutritionist or exercise physiologist or therapist, and I have no interest in becoming any of the latter. So just as I suggest patients see a psychiatrist/psychologist for OCD/dysmorphic and other symptoms, I will suggest that patients seek out others for health, nutrition, and wellness, when appropriate.

Dr. Bucay: At the end of the day, it's about setting expectations and knowing what works in our practices. In my practice, fat reduction and Ulthera are the most profitable treatments we offer, more so than Botox, fillers, etc., especially when you factor in who does the treatment and the cost of goods. We bring in more from injectables because of the volume we do—more patient demand for these services, less time to do the treatments, higher frequency per patient of this type of treatment.

I don't delegate injectables, but I do delegate these other treatments, which allows me to keep doing what I like to do.