CME: Re-examining the Optimal Use of Neuromodulators and the Changing Landscape: A Consensus Panel Update

April 2020 | Volume 19 | Issue 4 | Supplement Individual Articles | 35 | Copyright © April 2020

Published online March 20, 2020

Michael S. Kaminer , Sue Ellen Cox , Steven Fagien , Joely Kaufman , Mary P. Lupo , Ava Shamban

aDepartment of Dermatology, Yale School of Medicine, New Haven, CT bDepartment of Dermatology, Brown Medical School, Providence, RI cSkin Care Physicians, Inc, Chestnut Hill, MA dAesthetic Solutions PA, Chapel Hill, NC eSteven Fagien MD, Boca Raton, FL fSkin Associates of South Florida/Skin Research Institute, Coral Gables, FL gLupo Center for Aesthetic and General Dermatology, New Orleans, LA hAVA MD, SKIN FIVE, Los Angeles, CA

ance as dictated by social networking sites is more persuasive than ever, especially among younger people.6 A substantial percentage (81%) of Americans report going online daily, including 28% who are online “almost constantly” and 45% who go online several times a day.7 Social media plays a pivotal role in presenting aesthetic medicine as a feasible option for consumers active on these platforms. Traditional media channels are also creating enhanced awareness of aesthetic medicine. With the increasing shift from invasive to minimally invasive procedures, and new neurotoxins coming on the market, it’s an exciting time. Even people who had never considered treatment have a wider appreciation of what’s available. The consensus panel agreed it is imperative that physicians understand how various forms of media affect clients’ daily decision-making.

The millennial generation (born 1981-1996) represents the largest generation in US history, now representing more than 25% of the US population.8,9 To provide optimal counseling, preventions, and age-appropriate interventions for aesthetic patients, it is especially important that aesthetic clinicians be educated about generational differences in the manifestations of aging, since changes with aging often impact muscular activity as well as facial contours.10,11 These changes can be ameliorated by multiple modalities, including BoNT-A, but frequently not BoNT-A alone.

Younger women often seek aesthetic treatments to retain a youthful appearance, particularly once they notice initial signs of aging.12 Many come in because their friends are getting treated and there is far less stigma about talking about it as in the past. It has become much more the social norm than the exception. In the experience of the consensus panel, younger patients are especially likely to be interested in having only a single area treated with BoNT-A—glabella, forehead, or crow’s feet, for example—rather than global treatment because they are thinking of it as preventative maintenance, are focused on a certain area, and are cost-conscious. Millennials typically have a limited budget, which can present its own unique challenges, but they are also starting treatment at a younger age than patients in the past. Because it’s more preventative, the dosing strategy is often different. Younger patients tend to need a lower number of BoNT-A units and their treatment visits are less frequent, which enables them to better afford treatment. It is a different group, so the marketing strategy needs to be different. For example, many offices with a variety of clinicians at different ages are finding that millennials tend to gravitate toward the younger ones. The panel felt that it is likely a slightly better fit because patients just relate to them a little more closely.

The panelists agreed that younger patients are a little more challenging to treat than older patients they have traditionally seen. There are 2 distinct groups of young patients. At one extreme are those who have done research and have an opinion, but who also value the expertise of the physician to determine the best treatment options. These patients know the names of the BoNT-As, they sometimes know dosing, and they talk with their friends about it. When managing these patients, it is beneficial to anticipate that they will have done some online research and be ready to answer questions, which can help generate trust and demonstrate personal expertise of the physician above and beyond information found online.8 Some of these patients actually understand when you talk about agonist and antagonist muscles and explain that if they only get their forehead treated, their brow might drop. They have typically also watched the procedures online, so have less phobias, which also simplifies treatment.

The other group of younger patients believes they know more than their clinicians because they read something on the internet and come in with their own detailed treatment plan. The panel agreed that managing patients like this can be challenging at times, because they may want something done that the clinician knows from experience isn’t going to turn out well. The classic example is a patient who wants to totally get rid of her forehead lines—it’s an earlier mindset that persists. That pretreatment discussion can take a long time. The panel suggests that aesthetic physicians explain that the paradigm has shifted away from total immobilization, and that patients don’t need to be completely frozen to get great results. Patients who request treatment with high forehead doses often return a week later because their eyebrows are heavy. But they are frequently educated enough to learn from their experience and agree to listen more closely to physician recommendations.

Recent statistics from the American Society of Plastic Surgeons show that more Americans age 55 and older are increasingly seeking aesthetic procedures, with nearly 50,000 more procedures performed in 2018 in this group than in 2017.13 The panelists shared that as a group, baby boomers are a different kind of patient than millennials. These patients tend to come in because of a friend who’s looking great after aesthetic treatment or because they’ve had some sort of life change, like a divorce or the death of a spouse. These patients generally seek to reverse some negative effects of aging.14 They care about reviews, referrals, and being treated by the right person, and often have more resources than younger patients, so are less price sensitive.10

Another recent trend is patients requesting a particular agent, which was rare in the past, and is likely related to the expansion of social media and overall awareness. As additional agents are introduced, more people understand that they might provide different outcomes. In the past, many patients were not interested in switching agents. But now, those who trust their physician’s expertise often ask if they should try the latest agent. The panel felt that experienced aesthetic physi-