Everyone who works in an aesthetic practice will, sooner or later, encounter a patient who has unusual expectations or goals of treatment. The ability to ‘sense’ these types of patient early and to diffuse or deflect potential problems is an invaluable skill for the aesthetic practitioner to possess. However, most healthcare professionals do not innately possess these skills, and they are usually not taught on training programmes either. They can only be learned over time and through experience.
Aesthetic practices have unique issues with regard to some of the psychological motivations of a small subset of patients. As such, it is helpful for the aesthetic practitioner to be equipped with the correct tools to deal with these patients effectively.
In the authors' experience, lip augmentation seems to be a lightning rod for unusual and unnatural requests. Surgical practices see these issues regularly, especially with breast augmentation procedures; for example, a petite patient who wants extremely large breast implants that her frame could not support. But we also receive such requests in non-surgical practice too. It is the duty of the aesthetic practitioner to establish where the dividing line between exquisite and excessive treatment falls. Is it a hard line that can be clearly defined, or is beauty truly in the eye of the beholder?
In the authors' opinion, it is a bit of both. The practitioner has to decide what he or she is comfortable doing, bearing in mind the patient's wellbeing and considering too that the patient is a walking advertisement of the practitioner's work and skills, and of the aesthetics sector as a whole.
Concepts of beauty: exquisite Vs excessive
Attempts to define the concept of beauty have been around for millennia. It is generally accepted that the best we can do mathematically is the number, or geometrical proportion, known as phi. It has also been called the golden number, golden ratio or golden section, and was first defined around 300 B.C. by the founder of geometry, Euclid of Alexandria (Livio, 2003). Euclid defined phi by explaining that a line, called AB, is divided in extreme and mean ratios by C if AB:AC = AC:CB.
Or, put visually:
This ratio can be boiled down to 1.0 to 1.618, where A=1 and AB=1.6. This is directly related to the Fibonacci sequence, a series of numbers where each number is equal to the two preceding numbers added together. The nifty part is that, in this sequence, each number divided by the preceding number equals 1.6. Numerically, the sequence is 1, 1, 2, 3, 5, 8, 13, 21, 34, 55, 89, 144, and so on.
The golden ratio/Fibonacci sequence is found in nature, as well as in the human face. Focusing on the lips, in accordance with the golden ratio/Fibonacci sequence, on the frontal view the ideal upper lip:lower lip ratio is 1:1.6. The vertical height of the upper lip should be less than that of the lower lip (Kar et al, 2018). On lateral view, if a line is drawn from the subnasion to the pogonion, the upper lip should project 3.5 mm anterior to the line and the lower lip 2.2 mm. The upper lip should project slightly more than the lower lip again, about 1.6:1. (Sarnoff and Gotkin, 2012; Kar et al, 2018).
Some patients will request augmentation of the lips that throws this ratio off. Too much variation from the golden ratio can cause an odd appearance to the lips and disrupt the harmony of the face as a whole. Studies have revealed that when meeting someone, western observers have a propensity to fixate near the eyes during facial recognition (Peterson and Eckstein, 2012). A quick scan of the nose and mouth then follows, and the observer quickly returns their gaze to the eye area. If, when meeting a patient for the first time, their lips are the first things you see, it may be an indication of a previous excessive augmentation.
It can be helpful to invest in a pair of phi calipers, and use these to measure the patient's lips (see Figure 1). These calipers can be easily bought online, and can help the aesthetic practitioner to obtain objective data that can then be presented to the patient and used to guide their treatment.
Using the golden ratio to explain balancing the face to patients
By explaining to the patient how their lips fit (or do not fit) the golden ratio and how the lips and lower third of the face balance (or do not balance), the practitioner can educate the patient so that they can work together on a treatment plan. Engaging the patient in the process and arming them with information on the mathematical definitions of beauty can help to avoid future problems.
Using these calculations to explain to the patient how their lips correspond to the golden ratio, and therefore how they correspond to the rest of the face, the practitioner can help the patient to understand the level of treatment that is required to bring harmony to the face. Engaging the patient in this process, and providing them with information on the mathematical definitions of beauty, can help to avoid future problems with excessive augmentation.
Is the golden ratio the most reliable tool for quantifying beauty?
Of course, there is no agreed-upon standard to measure facial beauty, and this remains a challenging task (Harrar et al, 2018). Ideal proportions and measurements may not apply on a cross-cultural basis (Heidekrueger et al, 2017a), especially with regard to the lips, which vary in proportion across different ethnic groups. In fact, there is plenty of literature that supports the avoidance of the golden ratio as a beauty measurement tool. In 2008, Holland described Marquardt's mask (a mask derived from the golden ratio that is purported to describe the ideal facial archetype) as idealised for masculinised white women. Holland found that this mask does not describe the ideal face (Holland 2008), because its proportions are inconsistent with the optimal preferences of most people. While studying preferred lip ratios, Heidekruegger et al found that 60% of those surveyed preferred a 1.0:1.0 ratio rather than the 1.0:1.6 golden ratio. (Heidekruegger et al, 2017b). It is possible that other types of measurement tools, rather than phi, may be useful in guiding aesthetic practice.
Popenko et al found that the most attractive lip surface area represents a 53.5% increase from baseline, an upper to lower lip ratio of 1:2, and a surface area equal to 9.6% of the lower third of the face (Popenko et al, 2017). The same study found the 1:2 ratio of upper lip to lower lip to be the most attractive (Popenko et al, 2017). From reviewing the published literature, it is evident that the golden ratio, though potentially helpful in defining and quantifying beauty, is by no means an absolute. Each patient is different, and aesthetic practitioners should not feel bound to adhere to this measure when defining the ideal treatment plan for a patient.
Learning to say ‘No’
If a patient is requesting excessive or unnatural lip augmentation and is not swayed by the need to conform to the golden ratio, the practitioner's job is more difficult. The practitioner must decide, prior to treating patients, what he or she considers to be an exquisite lip and what is excessive. If a patient attempts to push for what the practitioner considers to be excessive, it may be time to say ‘No’ to the patient and decline treatment. This can be a difficult thing to do, especially in this people-pleasing, fee for service sector; however, it may be the best route to take, for the sake of both the patient and the practitioner.
Establishing the motivation for requests for excessive treatment
When the practitioner receives requests for excessive treatment, it is important to establish the patient's motivation for seeking this kind of treatment. Most importantly, it is imperative to determine if there is a diagnosable psychiatric problem contributing to the patient's request for cosmetic treatment. Does the patient show potential signs of having a personality disorder or body dysmorphic disorder? Is the patient ‘addicted’ to cosmetic treatments, and describe the effects as a short-term ‘buzz’ rather than long-term physical improvement? Has the patient been discharged from other aesthetic practices? Is the patient depressed? The patient's general appearance, demeanour and behaviour can reveal clues to underlying psychological issues (Elsaie, 2010). Diagnostic acumen requires an awareness of subtle signs suggestive of these potential problems, and the practitioner must intuitively observe the patient at all times (Elsaie, 2010). It can also be helpful to provide the patient with a checklist on consultation, which aims to establish their motivations for treatment and to detect any warning signs of underlying psychological issues.
If these disorders are suspected or diagnosed, they are best treated first by a mental health professional. Aesthetic practitioners should make themselves aware of an appropriate referral process for patients who they think are at risk of these conditions. Treating a patient who has a psychological condition with aesthetic procedures will not help the patient in the long term, as the underlying issue will still remain. Furthermore, no matter how good the treatment is, if the patient has an underlying psychological issue, it is likely that the patient will not be satisfied with the treatment, as it will have done nothing to treat the underlying problem. In this sense, not only might treating the patient have a detrimental impact on the patient's wellbeing, it could also have a detrimental effect on the practitioner's business and reputation.
If the patient presents as stable from a psychological perspective, but still requests over-enhancement of the lips, refusing can be difficult. Chesanow suggests ‘couching ‘no’ in an explanation’ (Chesanow, 2016). This is where the golden ratio, or other mathematical expressions of beauty, can come in handy. Saying ‘No, because that would disturb the balance your face, or distort the ratio of your lips' is more palatable, because it opens up the decision for discussion, and provides a reason to support it. Saying something along the lines of ‘I understand what you think would look appropriate, but allow me to suggest what I believe is the best option’ can also be effective. Sometimes a patient needs or wants to hear a different perspective and will value the aesthetic practitioner's opinion. Expressing an honest opinion in a gentle way can be refreshing for the patient, especially when the practitioner emphasises the fact that it is their job to act in the patient's best interests. Practitioners should not be afraid of opening a conversation with the patient; often, it is therapeutic for the patient to feel heard and understood.
Chesanow also suggests techniques, such as being willing to negotiate and being a ‘cheerleader’. In aesthetic practice, this may entail something along the lines of, ‘Let me fill around your lips first, to add support to the area—this may address your concerns’, or, ‘Your lips are absolutely gorgeous—I'm not going to touch them because it would only create imperfections’. Another effective method might be to highlight to the patient that many people would pay lots of money to try to achieve the lips they already have. Positive reinforcement by a professional in the aesthetic arena can be soothing for a patient, and allows them to see a different perspective.
If none of the above techniques are successful in dissuading the patient from treatment, then this may be considered a red flag—a warning to not treat him or her. In the case of an adamant, demanding patient, the only option is to defer. However, this should be done in a non-judgmental manner. One option is for the practitioner to inform the patient that they are unable to fulfil their request for ethical, medical and safety reasons and therefore, from the viewpoint of the medical professional, this treatment would not be considered professionally appropriate. The practitioner should let the patient know that they want what is best for them, and that they do not think that what is best for them in this instance is treatment.
Conclusion
The consultation is the most important part of the treatment plan. This conversation allows the practitioner to truly observe and understand the patient and their motivations for treatment. It is the job of the medical professional to hone in on behaviours and statements the patient makes that may be indicative of underlying issues. It is the duty of the healthcare professional to act in the best interest of the patient at all times, even though this may sometimes feel awkward or difficult. If the patient presenting to clinic is not likely to benefit from the treatment they are requesting, then the aesthetic practitioner should stand their ground, using the techniques discussed earlier in this article to politely decline treatment.
The vast majority of aesthetic patients will be grateful to have the professional opinion and expertise of their practitioner. With good communication and professional expertise, a treatment plan can be created that satisfies all parties, even when the plan is not to treat.