The first visit in aesthetic medicine: what to record

History: medications, allergies, medical background

A consensus meeting of nine European clinicians (2024) says to collect an up-to-date medication list and a complete medical history: allergies, illnesses, surgeries, immunizations, pregnancy and breastfeeding. Ask about anticoagulants explicitly, because they raise the risk of bruising. Also ask about previous aesthetic treatments and how satisfied the patient was with them. The Italian code of medical ethics wants the history and the objective findings in the record (art. 26).

If you use Fibonacci, dictation fills in the facts the patient reports (allergies, medications, conditions, pregnancy, previous treatments) and leaves them for your review: nothing reaches the record until you press the button.

Skin: phototype and photoaging

The Fitzpatrick phototype runs from I to VI and rests on how the skin reacts to the sun: type I always burns and never tans, type VI never burns. Because the classification relies on what the patient reports, it can be biased: ask how the skin really reacts. The Glogau scale describes photoaging in four grades: grade I has no obvious wrinkles, grade II shows dynamic wrinkles with facial movement, grade III has wrinkles at rest, and grade IV has diffuse wrinkles with skin laxity. You assign the grade by looking at the skin and at the face in motion: write the scale, the grade and the date.

The patient's point of view

The 2024 European consensus suggests giving the patient a short questionnaire before the visit about expectations and self-perception. For the face there is FACE-Q Aesthetics, a validated questionnaire with 37 scales covering facial appearance, quality of life, naturalness and adverse effects of treatment. A 2024 paper on the 360° approach proposes open questions before directed ones (for example, “why now?”) and at least 45 to 60 minutes for the first consultation.

Expectations and signs of body dysmorphic disorder

Write down what the patient expects from the treatment, in their own words. For body dysmorphic disorder there is a short validated screening questionnaire, the BDDQ: in a study of 344 cosmetic surgery patients in Saudi Arabia it was positive in 19.2%. It is not a diagnostic tool: a positive result flags a possible case and a mental health specialist has to confirm it, which is where the authors recommend referring positive patients. Record the result and what you decided.

Baseline photographs

Take the photographs before any treatment. The protocol described in the 360° approach typically involves 6 to 12 photographs, with several views (frontal, lateral, oblique) and the same lighting, position and settings at every visit. Photograph the face in motion too: smiling and expressions show what is not visible at rest. How to take, store and publish them is covered in the guide on before and after photos.

Information, consent and plan

Law 219 of 2017 requires free and informed consent, documented in writing and placed in the record, after information on diagnosis, benefits, risks and alternatives. For aesthetic medicine the code of medical ethics adds that the information given before written consent must not raise or feed illusory expectations and must identify alternatives of equal efficacy (art. 76 bis). The record must also show how and when the information was given and the terms of the consent (art. 26). The plan comes afterwards: for each step the reason, the expected result and the cost in time and money, over a 12-month horizon to be reviewed.