Three months in, you take the follow-up photographs and the patient looks worse than at baseline. She is delighted, sitting in your chair, waiting to hear how it went.
What you do in the next sixty seconds determines whether you find the actual cause — and most clinicians reach for the wrong explanation first.
The Instinct to Blame the Patient
Dr. Chris Croley, Empire's Chief Medical Officer, names the reflex and then refuses it.
“I always will usually start with our process and our workflow, rather than going right to what did the patient do different,” he says.
His reasoning is uncomfortable and correct: “As a practice owner, unless you're doing all these steps yourself, there are also other errors that occur in the process.”
The questions he asks first are about his own building:
- Was the toxin mixed the same way?
- Did somebody forget and leave it out on the shelf?
- Did I change my dilution, or the way I was reconstituting the biostimulator?
- Did we use a different PRP machine?
“We try to standardise it,” he says, “but I look for where gaps could have occurred — that maybe there was something wrong with what we did as well.”
And the reason he raises it publicly: “Many times the providers will try to go and blame the patient.”
Then Investigate the Patient — Without Accusing
Patient factors matter enormously. The order is what matters.
Maritza Mejia FNP describes a case that is worth keeping in mind whenever a result appears to reverse.
A patient had completed biostimulator treatment and microneedling. At three months the photographs looked worse. “I was like, oh man, what happened? She looks worse. How am I going to show this picture?”
Mejia went back in and asked what had changed. Nothing, the patient said. Had she lost weight? No — she weighed the same.
“So now I started thinking. The weight is the same. Guess what — she was training for a triathlon. So she was losing fat but she was gaining muscle. That's why she still weighed the same. But her face…”
The scale had concealed a substantial change in body composition, and the face had paid for it. Neither the patient nor the weight reading would have revealed that without someone asking the right follow-up question.
And the resolution: the patient went to her race, came back a month later, resumed, and the results were, in Mejia's words, amazing.
Ready to put this into practice?
Explore Empire's hands-on, CME-accredited Aesthetic & Injectable Training courses — live patients, expert faculty, and ongoing mentorship.
Why GLP-1 Changes This Conversation
Mejia now treats body composition as a standing part of biostimulator planning, and she is candid about why.
“These people, they do GLP-1 once and they tell you like, oh no, no, no, I'm going to have proteins,” she says. “I don't trust the patients nowadays, because it's a lot of education.”
Her instruction is that a patient having biostimulator work needs adequate protein and collagen support, because the treatment is asking their body to build something. Her analogy: it is like a dental cleaning — if you do not brush morning and night afterwards, the appointment only did part of the job.
Melissa Pulcini-Buttine PA widens the history further: go back to the foundations — nutrition, exercise, lifestyle, stress. Did the patient go through something traumatic, a divorce? Suddenly they are losing hair and their skin is changing. She describes it as investigative work rather than interrogation.
The Order That Works
- Audit your own workflow first. Product, reconstitution, dilution, storage, device, technique, who performed it.
- Check the comparison itself. Same position, same lighting, same distance? An apparent decline is sometimes a photography problem.
- Then the patient history — weight and body composition rather than weight alone, training load, nutrition and protein, sleep, stress, major life events, new medications including GLP-1s.
- Show them the photographs. Mejia does, as a matter of course.
- Change the plan rather than repeating it.
Do Not Get Stuck in the Pathway
Mejia's rule for what happens next is the most portable part of this.
“If we don't see a change, we change treatment,” she says. “I may tell you you need maybe a peel, a microneedling, but then the third one, we don't do another microneedling. Maybe you need another peel. So I don't get stuck to the treatment that we did at the beginning, because we modify as you come.”
Repeating a protocol that has not worked because it is the protocol you sold is how a patient's trust erodes. Croley's conclusion is that acknowledging it openly and producing a new plan is what keeps people: most of those patients, he says, will stay with you for years.
Telling Them Is Not Optional
Croley notes that this is where newer staff struggle most — they get frightened to show a patient a photograph that does not look better.
Pulcini-Buttine puts the consequence of the alternative plainly: a great deal of what escalates toward malpractice involves a provider who was not honest, did not help, and blamed the patient. Her observation is that patients respect you more for being able to manage it and explain it.
Results vary — genetics differ, products suit some people and not others. Saying so, with the photographs on the screen and a revised plan attached, is a stronger position than any explanation invented to protect the result.
Frequently Asked Questions
What should you check first when a treatment does not work?
Your own workflow. Whether product was reconstituted and stored correctly, whether dilution or technique changed, whether a different device was used, and who performed the treatment — before investigating what the patient may have done differently.
Can weight training affect facial aesthetic results?
Body composition can. In one case a patient training for a triathlon lost facial fat while gaining muscle, so her weight was unchanged while her face looked noticeably different. Weight alone can conceal that, which is why body composition belongs in the history.
Do GLP-1 medications affect biostimulator results?
Faculty treat rapid body-composition change and inadequate protein intake as factors that can undermine results, and now discuss nutrition and protein support as part of biostimulator planning rather than as aftercare advice.
Should you show a patient photographs that look worse?
Faculty say yes. Concealing them damages trust, and honesty paired with a revised plan is what keeps patients long term — whereas blaming the patient is a recognised route toward complaints.
Disclaimer
This article is educational and intended for licensed clinicians. It is not medical advice and does not establish a clinician-patient relationship. Individual results vary. Treatment decisions should be made by a qualified clinician who has examined the patient.
Claim Your Prize!