Sammi Khalifian, M.D., started his medical career studying an area of medicine that is about as different from medical aesthetics as you can get, the field of neurosurgery. “My father had a traumatic brain injury and I went to medical school really to do neurosurgery. I went to Hopkins because that was like the mecca of neurosurgery,” he says. “I very quickly became disillusioned with neurosurgery because I felt that even the best of outcomes were not great outcomes and it kind of was hitting very close to home. But for the last decade, my identity was very much a surgeon. So, now having gotten to Baltimore from Southern California, I was like, what the hell am I going to do now?”
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Sammi Khalifian, M.D., started his medical career studying an area of medicine that is about as different from medical aesthetics as you can get, the field of neurosurgery. “My father had a traumatic brain injury and I went to medical school really to do neurosurgery. I went to Hopkins because that was like the mecca of neurosurgery,” he says. “I very quickly became disillusioned with neurosurgery because I felt that even the best of outcomes were not great outcomes and it kind of was hitting very close to home. But for the last decade, my identity was very much a surgeon. So, now having gotten to Baltimore from Southern California, I was like, what the hell am I going to do now?”
It was after attending an intriguing lecture given by the plastic surgeon running the face transplant program at Johns Hopkins that Dr. Khalifian’s interest in medical aesthetics was first ignited. He was invited to work in this surgeon’s laboratory devoted to facial transplantation, as well as related work in upper extremity transplantation, with Dr. Khalifian focusing on immunology in relation to transplantation success. Discovering that the skin was the tissue most likely to reject transplant, his primary focus became skin immunology. However, Dr. Khalifian once again found himself disillusioned by the realization that the field of facial transplantation was not one that would have the far-reaching positive impact on a larger patient scale he sought in his career.
As residency applications loomed close, the pressure to find a field that would allow him to utilize a combination of his different medical passions to help patients left Dr. Khalifian at a loss until he considered the possibility of dermatology as the answer to his dilemma. Thus, after earning his medical degree from Johns Hopkins in 2015, he went to Harvard University to embark on his dermatology residency. “So I applied to dermatology, I got in and then I started to really enjoy aesthetics. I initially started doing aesthetics in connective tissue disease patients, working in conjunction with rheumatology and dermatology to create a connective tissue disease cosmetic clinic and I really liked it. That was sort of where it all began. Now I have my own practice and we focus on aesthetics, but also do medicine and surgery as well. We read slides, so we're doing pathology; we have clinical trials units, so we're doing research; we have a training center, so we do teaching, etc. So that really allowed me to check all the boxes of what interested me. I have a lot of varied interests and I don't want to forgo one to pursue another. And so through dermatology, I found that I actually was able to really push on all the fronts without compromising or being mediocre at one or the other.”
Medical Precision in Aesthetics: Diagnosis & the Language of Feelings
Having patients use the language of feelings to explain their concerns, helps doctors better pinpoint what areas to treat to address those specific aesthetic concerns.Image by LuneVA/peopleimages.com at Adobe Stock
Dr. Khalifian states, “There’s basically two things that happen when you ask patients how they feel. When I invite someone to tell me how they feel about the way they look, they may say I see this or I see that, pointing to a fold or a crease. I’ll sort of redirect them, and say, ‘Ok, how do you feel?’ I really try and get at what the feeling that they’re experiencing is. Sometimes it may take a couple rounds of redirection until they’re like, ‘oh, you’re asking me about how I actually feel about this,’ because I think no one’s ever asked them this question. The other thing that will sometimes happen is they’ll say, ‘I don’t know doc, just tell me what you think.’ I very much avoid this, only because if you can’t see it, I don’t want you to see it. You don’t want me to tell you what to see. Once you see it, you can’t unsee it. So, I very much push back on this, and I won’t answer that question.”
A crucial element of this is understanding what kind of language patients have at their disposal that will best facilitate their ability to communicate their aesthetic concerns. Dr. Khalifian recognizes that while patients may mistakenly try to use medical terminology related to aesthetics to explain their aesthetic concerns, this is not language they understand well enough to adequately communicate their concerns. Instead, he encourages the use of language patients do have familiarity with that can communicate their concerns to a medical practitioner, the language of feelings.
“No one woke up today and said, ‘Let me go to Dr. Saami’s chair and let him tear my face apart,’ right. They saw something that brought them in. They just may not have the language to tell me, and it’s because they’re thinking that they need to use language like medical jargon that they don’t have. They don’t have the language to translate what they are feeling into what can be done. This is why I use feelings because they definitely have that language. I just try to invite people to tell me how they feel. Then this leads me in the right direction and the feeling allows me to cue into the part of the face where they are seeing these issues they want to be treated. If you’re feeling angry or tired, angry and tired is up here in the eyes. If you’re feeling sad, or like you look sad, sad is usually around the mouth. It’s worked for me and I think it also builds report,” explains Dr. Khalifian.
Commodification of Aesthetics: Impact on Medical Precision
Practitioners are stewards of the public trust, and earn that trust by guiding patients through their aesthetic journey while prioritizing their mental and physical well-being.Image by blackday at Adobe Stock
This disconnect in the medical aesthetics industry between the medical expertise and role of the doctor and the patient’s perception of that role compared to the perception of traditional doctor/patient relationships creates numerous problems when it comes to the aesthetic practitioners ability to provide optimal treatment to said patients.
“This taps into this idea of the value proposition and trust. When you go to an aesthetic provider, they may give you some recommendation and let’s say it is some full face correction. You may say, ‘well, I don’t want to do this, I want to do that.’ Much like going to that cardiologist, you don’t go to the cardiologist and have him say you need four stents and a coronary artery bypass surgery and you say, 'no, I’m just going to take a statin.' No one does that. Somewhere along the lines in this journey of commodification that I was alluding to, it became seemingly appropriate to do that, but even in aesthetics, you don't get one breast implant. It's challenging, particularly with injectables, because getting a complete result sometimes does require you to do higher numbers of units, multimodal treatment or more syringes, and patients are not amenable to that. This is where for me, it's been challenging to build out both trust and the value proposition. They may trust you, but the value proposition is either not there or it's just out of range,” states Dr. Khalifian.
One of the biggest ways Dr. Khalifian sees this resulting in issues for aesthetic practitioners is that it hinders doctors’ ability to provide optimal treatment for patient concerns. He explains, “I think one of the issues that I also see is we don't want to dilute the results that you can create, but you also don't want to not be able to treat your patients. So, there's a balance and it's hard to sometimes achieve that balance based on budgets, or outcome expectations, timelines, downtime acceptance etc. Some of the coolest things I can do require significant downtime, but what I've learned recently is that downtime is perhaps the thing that keeps people away the most. While I can do a crazy good CO2 or full-field erbium laser resurfacing and take 15 years off someone's face, they have to give me a month of downtime, and they're just not going to do that. So, they'll take a fractionated approach, and maybe I'll take four or five years off their face, but that's more acceptable to them even if it costs more than giving me that kind of downtime.”
These challenges faced by medical aesthetics practitioners are partially due to the remaining stigma around the field, both among consumers as well as academia. “This is very commonplace. I think even in medical school and residency there is a habit of dissuading medical students from going into aesthetics. Even in dermatology residency programs there is a screening to determine if you are just doing this because you want to go into aesthetics. So, there is this very strong push back on aesthetics from academia and so you see it outside of academia as well,” shares Dr. Khalifian.
Commodification of Aesthetics: Trends & Misunderstood Treatments
Dr. Khalifian developed a technique for the widely misunderstood masseter botox trend that achieves a global treatment of the masseter, which is necessary to effectively treat TMJ disorder.Image by Kalim at Adobe Stock
“There are also trends now that are very much fads that people employ because they want to, without really understanding what they're doing and why. Someone popularizes a treatment, and it becomes the new fad. Traptox was one of them and I think, ‘you know, why? What is the benefit here?’ I think that what people don't understand is when it's done improperly, you get off-target pain in your neck or your scapula. Keep in mind that in the United States the majority of injectors are non-physicians. Most of the people offering this treatment, even if they are physicians, their understanding of the trapezii is probably not the same as their understanding of the glabella. So, I find that these types of misunderstood treatments tend to just be just fads.”
One of these treatment trends Dr. Khalifian has found to be misunderstood by both patients and aesthetic providers is masseter botox. He says, “Masseter botox is very misunderstood by most providers. I've been looking at the masseter treatment for probably five years now. It all began when I started doing masseters and I noticed it involved putting a lot of units in very small areas right next to each other. If you happen to hit the rhizorius muscle, you're going to create a smile asymmetry. The other thing was you would see an accentuation of people's discomfort in the joint afterwards, when in reality a lot of patients were getting this treatment to alleviate discomfort, bruxism and TMJ disorder.”
Once he recognized the problems inherent in the established masseter botox treatment technique, Dr. Khalifian turned to his knowledge of anatomy and physiology to develop an effective injection technique that addresses these issues. “Think about temporal mandibular joint disorder (TMJ) - where is the joint? The joint is up in the superior aspect of the masseter. However, where do I would say 98% of people inject the masseter? They do three points down the jawline, but the joint is up here, and the masseter muscle stretches from the zygoma to the mandible, posteriorly from the gluteal angle and anteriorly to the notch. It's this massive, thick muscle, so if I only inject the inferior portion of the masseter, what it does is cause the upper pole of the masseter to compensate and work harder, which is going to make it worse. True TMJ disorder treatment requires a global treatment of the masseter, from superior to inferior, lateral to medial, etc. In this manner, you can use less units than what people realize, only using one to two units in each injection site, working from deep to superficial because you want to get the whole thickness. Most people don’t inject that way. So even with masseter botox, there's a misunderstanding of what we're doing and what message we’re giving patients, but most people don't know that,” he explains.
Commodification Vs. Medical Precision in Aesthetics: Pushing Boundaries
Dr. Khalifian emphasizes the need for aesthetic practitioners to push boundaries and question why a certain treatment technique is used and if there is a better way it could be done. Practitioners need to challenge themselves to improve and evolve aesthetic treatments and techniques through understanding the science and medicine behind them. Rather than accept the current technique used for certain treatments whether it is the most effective method or not, practitioners can use their medical expertise to advance aesthetics.
He states, “One of the things that I always ask is why? Why are we doing these things the way that we're doing them? If someone can give me a well thought out answer and reason as to why they do it a certain way, great. What we often hear is, ‘I do it this way because this is the way I was taught.’ If you ask why they were taught that way, the answer you get is, ‘I don't know, that's just the way I was taught.’ That’s just not good enough. This is when you go back to anatomy and physiology to understand why you would do it this way instead of another. That's science and medicine; it's trying to understand the mechanisms of what we're doing because medicine is still medicine. It’s this idea that we should be pushing forward the boundaries and understanding what we're doing.”
Despite needing certain improvements in this respect, Dr. Khalifian also calls attention to the boundaries that are being pushed forward thanks to positive trends in aesthetics that are bringing awareness to diversity and the needs of patients that have been underrepresented in the past, such as the transgender community.
“It's even things like blurring the lines of what is masculine and feminine, right? It’s understanding that just because idealized versions of male and female beauty may be something that previously was suggestible, masculinization and feminization is as much a subjective issue and personal issue as it is some idealized form of what beauty means. A square jaw in a woman may be desirable or softer features in a man may be desirable,” says Dr. Khalifian. He gives the example, “When jawline filler in United States started to become more commonplace, what we saw was a lot more square jaws, which previously would have been very masculine and thought of as not appropriate in women, but a lot of women are specifically asking for that. When you look across different anthropomorphic cultures and genders across the world, one of the things that you'll see, particularly in Eastern European women, is they have a squarer jaw compared to Asian cultures, which have more rounded lower faces. This is purely a reflection of other aesthetic trends. What's hot today may not be hot tomorrow, but I think our job as providers is to really understand what patients are after, what's motivating them and why and whether that aligns with our own goals, values and abilities to create those kinds of outcomes.”
Combatting Commodification: Prioritizing Patient Mental Health in Aesthetics
W.A.I.T. and listen to avoid drawing attention to imperfections patients aren't aware of and address their specific aesthetic concerns.Image by Mediteraneo at Adobe Stock
Vulnerability and empathy are vital to earning patient trust and creating a safe space in which patients can feel comfortable expressing their own vulnerability. Considering the vulnerable nature of sharing appearance-related concerns and the emotional and mental wellbeing weaved into a patient’s aesthetic concerns, vulnerability and empathy from practitioners is particularly important in medical aesthetics.
“My view is one of diplomacy, understanding and recognition of the vulnerability that's being exchanged here, as well as being vulnerable with your patients. People feel very uncomfortable with that. The other day, a patient was telling me about her husband's experience, who had just had a brain tumor, and that he had been paralyzed with surgery. My own mother had been diagnosed with a brain tumor a few months prior and she hadn't had surgery, and as the patient was crying, I started crying. Real connection happened at that moment. I was vulnerable, the patient was vulnerable and she felt cared for; she felt seen. I think some people pay lip service, but I'm trying to live it. When you talk to people, you can tell if someone is being genuine or not. Empathy can't be taught. Either you're an empathetic person who feels or you're not. I've been fortunate in that the network of people around me are all very empathetic. It also challenges me to reflect on myself and my practices,” says Dr. Khalifian.
Prioritizing Mental Health: Learning to Listen & W.A.I.T. (Why Am I Talking)
One of these people that have helped Dr. Khalifian in his empathetic and considerate approach to patient care is his wife, Chandra, who happens to be a clinical psychologist. Her expertise in psychology has proven invaluable, with Dr. Khalifian pointing to one piece of advice in particular that challenged him to rethink his approach to communication that helps facilitate meaningful interractions with patients during consultations. The beauty of her advice lies in its simplicity, as it utilizes a simple, easy to remember acronym that gets straight to the point.
“My wife is a clinical psychologist and I talk a lot, so she said to me, ‘You need to stop talking and listen.’ I was like, ‘I know, but I forget.’ She said, ‘Just remember this acronym, W.A.I.T.: Why Am I Talking.’ It hit me. Am I just talking to hear the sound of my voice? I'm going to get way more out of this interaction if I stop and listen to you than if I'm just talking to you. It's very uncomfortable for people, but I think it is appropriate to challenge ourselves to just stop and listen. I'm also a fixer, and particularly in medicine, the desire is always to fix the problem. But sometimes it's just recognizing that the problem exists. That in and of itself is reassuring. It makes you whole in some ways.”
Dr. Khalifian leaves us with this final insightful observation, stating, “All of these things that we're talking about are soft skills, but the difference is not how good of a botulinum toxin injector you are or how good are you at using the appropriate settings on an energy-based device, right? It's about how good you are at connecting with someone, understanding their needs, reassuring them when times are tough and holding their hand during the post-operative period. I think caring for someone is the essence of all of those soft skills. The meat and potatoes of your practice are the outcomes that you can create, but all the accoutrements, if you will, are the soft skills. They make the difference between a doctor you'll keep going to and one you won't.”
