When NOT to Inject: Red Flags in Aesthetic Medicine | Patient Safety First | Vitality Unfiltered

Vitality Unfiltered Podcast

Host: David J. Bauder, PA-C
Guest: Alicia Sanderson, MD

In this episode of Vitality Unfiltered, we explore a topic that is often overlooked in aesthetic medicine—but is critical to patient safety and long-term outcomes: knowing when not to treat.

David J. Bauder, PA-C, founder of Weight Loss & Vitality, and Dr. Alicia Sanderson, facial plastic surgeon, discuss the importance of identifying red flags prior to performing injectable treatments such as dermal fillers and neuromodulators.

While many conversations in aesthetics focus on technique and results, this episode shifts the focus toward clinical judgment, ethical responsibility, and thoughtful decision-making. Not every patient is an appropriate candidate for treatment, and recognizing when to defer or decline a procedure is a key component of responsible care.

The discussion covers a range of red flags, including medical contraindications such as infection or impaired healing, psychological readiness, and unrealistic expectations often influenced by social media. The episode also highlights the importance of patient education and shared decision-making in reducing risk and improving outcomes.

A central message of this episode is that patient safety must always take priority over demand. Saying no, when appropriate, is not a limitation—it is a critical part of delivering ethical and effective medical care.

In This Episode We Discuss

• The definition and importance of red flags in aesthetic medicine
 • Medical contraindications that may require delaying or avoiding treatment
 • Why compromised or inflamed skin should not be injected
 • The risks of overfilling and poor clinical judgment
 • Psychological readiness and its impact on outcomes
 • How unrealistic expectations can affect patient satisfaction
 • The role of social media in shaping patient requests
 • When and why providers should defer or decline treatment
 • The importance of patient education and informed consent
 • How ethical decision-making protects both patient and provider

Key Takeaway

Recognizing when not to treat is just as important as knowing how to treat. Identifying red flags, managing expectations, and prioritizing patient safety are essential to responsible, high-quality aesthetic care.

Contact Weight Loss & Vitality

📞 Call: 571-550-9000
 🌐 Visit: https://weightlossandvitality.com

About Vitality Unfiltered

Vitality Unfiltered is a medical podcast exploring the science of hormones, longevity, metabolism, weight loss, aesthetics, and precision medicine.

Each episode provides clinical insight from healthcare professionals who treat these conditions every day.

Our goal is simple: to help people better understand the biology of their health so they can make informed decisions about wellness, prevention, and long-term vitality.

⚠️ Disclaimer
This podcast is for educational purposes only and does not constitute medical advice. Listening to this episode does not establish a provider-patient relationship. Always consult your qualified healthcare professional regarding medical concerns, diagnosis, or treatment.

Transcript

SPEAKER_00 0:00

Vitality.

SPEAKER_01 0:02

Vitality unfiltered. Unfiltered.

SPEAKER_00 0:05

With David Bowder.

SPEAKER_01 0:10

And we're back for another episode of Vitality Unfiltered. Joining me today is Dr. Alicia Sanderson. Today's topic is when not to treat. And this can be a very challenging thing because sometimes patients come in with certain expectations, and it's our job to be able to tell the patient that this treatment option that they're choosing is not necessarily the best option. So to help walk through this today is Dr. Sanderson. And let's get started with what do you what guidelines do you use, you know, when when you decide, I'm not going to inject this person, I'm not going to do surgery on this person.

SPEAKER_02 0:45

Correct. Yeah. And I think that that's a, you know, that can that's a big topic, a broad talk, and there's lots of reasons for it. So clearly based on what you're doing and how you're doing, contraindications to doing a procedure. So for example, if it's Botox, if you have a history of a neurological disorder like Guillain Beret or something like that, that's a contraindication for doing any kind of neuromodulator because that can cause recurrence of that symptom. So if you don't know what the disease is, or you don't know you've had a neurologic disorder, then you're probably okay for Botox. But if you had Guillain Beret or something like that, then you are gonna not. So absolute contraindications. We do not recommend Botox during pregnancy and lactation. It probably is safe. There's been some studies done on cows, like for lactating cows, and they've injected high amounts of Botox and it was non-detectable in the milk. And the same thing, there's lots of women who get Botox in the early trimester of pregnancy and they do just fine. We're doing really small amounts into muscles, so there are probably not any systemic levels in there. But it's not been researched, and nobody wants to take the, you know, the risk of doing that, right? We people have miscarriages for all sorts of reasons. You don't ever want to contribute it to a cosmetic procedure. So something like that, we would not do Botox and fillers and fillers. Um, like so fillers, um, contraindications for those is allergic reaction to the filler that you would do it. Um, more, you know, kind of like softer areas that we would get into for not doing fillers is if if somebody doesn't need it, right? Um sometimes people are overfilled. And now this becomes more of a subjective approach from a surgeon's standpoint. And I think that it's going to be different depending on who you go to. But for me personally, in my practice, I don't want to do any harm, right? I don't want to overdo it or, you know, make somebody look um, you know, too filled or not doing it. And a lot of that becomes a conversation, right? So we'll if somebody comes in and they want, you know, filler in their cheeks and I feel like their their cheeks are already really prominent, you know, we try and get to like where do you feel those um, you know, why do you want it in your cheeks? What is it that really bothers you? Because a lot of times it's not the cheeks. It may be the tear trough, it may be, you know, they're losing volume someplace else that needs to um to go into it. If it's just more their personal preference, like say lips, lips are another one. I like to be very, very conservative on the lips. Some people want a little bit more lips. If I think that their expectations are reasonable and I discuss with them that their lips are going to look artificial, they're gonna look in there and they do it, that may be something that we can come to terms in. But we I think there's a lot of importance to having clear expectations and having the expectations meet on both the um the provider and the patient standpoint to make sure that goes through. And then when you get to surgical reasons why you would would or not do surgery, that's you know, definitely um more complex. Um so rhinoplasty is a fantastic example of that. You know, um, you know, patients' expectations with rhinoplasty and the risks of rhinoplasty um and the outcomes in there. If I do not feel like I can meet a patient's expectation of what they want and what I want, a lot of times I will describe or talk about what I can do and give them some time to think about it and say, come back in a follow-up appointment. And then they come back in a follow-up appointment and we discuss it again. But definitely if our expectations don't match, then we can't, you know, I don't think it's great to move forward. And I think that's important from a patient perspective as well. Because if you don't feel like your surgeon's gonna give you what you want, right? If you feel like what their recommendations are for fillers or Botox aren't gonna meet the problem that you that you have, then that's a good time to take a step back and maybe find a surgeon that you do have a good, you know, rapport with or something that you feel like you're on the same page of expectations. You know, definitely for surgical aspects, you know, high surgical wrists, people that are on um on blood thinners, you know, heavy smokers, I will not do a facelift on a smoker. Um, I won't do a revision rhinoplasty on a smoker. Smoker, um, smokers impair the um the vascular healing in there. So they have much higher rates of wound heal. And the number one mantra of medicine is do no harm, right? So if I if people have significant core morbidities or they have lifestyle choices that are contraindicated to a good outcome, that may be a patient that I just feel like.

SPEAKER_01 5:26

What about connective tissue disorders?

SPEAKER_02 5:28

So actually, you know, funny thing, in the face we get away with a lot. So I will I've had a lot of patients, you know, that have been immunosuppressed because of um organ transplants or things like that, who've had connective tissue disorders. And I, you know, you get a little bit hesitant with ablative laser surfacing procedures and things like that. And so uh sometimes I'll go really slow. Like I really do a really light treatment, or I'll do a little test spot, or I'll do, you know, like we do a different procedure, a smaller procedure, and they heal up just fine. Typically on the face, you can get away with a lot because it has a great blood supply and it tends to heal well, very different than the body and doing it. So, like a plastic surgeon may not do uh, you know, removing a pannis of skin because that's not going to heal, but the face you can do a lot on. So I've been okay with immunosuppressed people and their healing process as far as going through and um doing, you know, facial procedures and surgeries on that aspect, even ablative surgeries. Some of the treatments you have to be careful about the um the pigmentation level of your skin. So if you are really fair, um, we have like a Fitzpatrick scale that actually grades your um your likeliness to burn and the color, the lightness of your skin. So if you're really fair skinned, I can go to town with an ablative laser and do a lot of work because there's not a lot of pigment to remove from it. But certain like darker pigments, I actually I may not be able to use the laser on. I cannot do certain chemical peels on it, or I have to do a really light treatment. So depending on what the goals are, if I don't have the tool to fix that, if you have a lot of pigmentation problems, I can't if you have a lot of pigmentation and you have pigmentation problems, I can't do the same thing on a really on a Fitzpatrick 1, which is really light skin, and a dark skin, because I would cause problems like hypopigmentation and things like that.

SPEAKER_01 7:15

Aaron Ross Powell Sometim I would probably bring up too, you know, like in my mind, I I I consider somewhat of a sensitive top topic, I guess, but the emotional the emotional position that the patient's in. Like they have to like let's say a patient has d anxiety. Yep. And maybe they have a can maybe their aesthetic procedure creates their exact makes their anxiety worse. Right. But if we do the procedure and they don't get the exact outcome that they want, I'm gonna you know it's gonna even amplify more, right? So that has to be a consideration too.

SPEAKER_02 7:44

Aaron Ross Powell It's huge. So in aesthetic surgery in general, a huge component of what we do as aesthetic surgeons is we assess people's emotional and mental readiness for surgery. So I will say 90% of what I do is psychology, right? So like I can do a surgery, I can do a rhinoplasty on anybody. I can operate on your nose, I can do those things. I have the skill set to do that. But the majority of what our visit is, is assessing is somebody stable? Are we doing the right thing? You know, if somebody comes into me and says, my husband's leaving me and, you know, he, you know, always hated my nose and didn't want my nose, so I want to rhinoplasty for that. That's like not the right motivation to do it. You want to do something that is because the patient wants it. Like I don't like the hump on my nose, I've always been self-conscious. That's a great patient. If my husband's leaving me and, you know, your nose, you know, because it's my nose in there, then he's gonna leave you anyways, right? So my surgery isn't going to fix that. So there's a huge component in aesthetics about, you know, psychology. And also it's like the procedure and the healing process. So it's important when you meet with your provider or whoever's doing it, that your expectations meet. It is what you want, right? If you go in and they do something and you're not prepared for the outcome or it isn't what you want, the psychological aspects of having your face changed, not the way you want it, not the way it looks, is huge. Like I won't, I if I'm doing a rhinoplasty, I will take your nose and make your nose fit your face and take care of those distracting features. My goal is not to change your identity by taking somebody else's nose and putting on there. And I think that's the same thing with facelifts and facial rejuvenations. Your goal of these surgeries are to make you look well rested. My patients come in and they're like, nobody can tell I had a facelift. They all say, something's wrong, you look really good. Did you go on vacation? You know, did you lose weight? Did you do those things? You don't want somebody to come in and be like, oh, that was a nice facelift you had done, right? And going in there. So depending on what the goals of the patients and people with if they have very unrealistic expectations or they're looking for something else to fix, that's a really important conversation to have with them. And again, sometimes people just come in and say, hey, I'm here for, you know, I I want to get some Botox for my nasal label folds. Well, you know, Botox doesn't treat this. That's filler, right? So some of those things are is the education component and saying, hey, these are the things that I can and can't do, and working together with it. And I think part of our job is to work with somebody because the luxury of aesthetic aesthetic medicine or, you know, you know, functional medicine or doing it is that we can listen to the patient. We can figure out what they want to fix. So a contraindication for me doing a procedure is if my procedure is not gonna fix that.

SPEAKER_01 10:49

Correct. Yeah. A lot of people come in too about what they just saw on social media, the latest gradient. Right. And you're like, you know, yes, that they they presented that very well on social media with Airbrush or you know, AI generation or whatever. Right. That's not reality. Trevor Burrus, Jr. Right.

SPEAKER_02 11:05

And that's not what you're gonna have. So a patients come in all the time and they're like, oh, I want this, I want that lift. I'm like, oh, that's not for it. I see a lot of it now. And like, I mean, we're we have very well-educated consumers. And so they'll come in, they'll say, like, oh, I want, you know, I want this type of facelift, or I want this kind of thing done there. But it's not a one-size-fits-all model. So part of my the assessment when somebody comes in and we talk about them like, can we get on the same page? Can we do the whole thing? If they come in and they just want this one thing, and I don't think that that matches to what, you know, to what I see, I think that that's the great opportunity that, you know, that they talk to somebody else. I love second opinions. I love when people shop around and they meet um different people, because this is not a one-size-fits-all. If you come in and you have tonsillitis, there's one thing we can do, take out your tonsils, right? You know, like recurrent tonsillitis, I should say, you know, but when you're um when you you're talking about aesthetics and looking and what your goals are, how I do it may be different than how somebody else does it. And it's really important to have a good therapeutic relationship and that that it's in there. And there are, you know, body dysmorphic, you know, issues out there that can happen, but also society creates you know, body dysmorphic things, right? They come in and they think they need to look this way to look young or to look good. And I don't think that that looks young. You guys is that what bothers you? And they're like, no, but people say I should have this done. And and that's that's where our job as the I kind of feel like as the educator is to take away all the marketing that we are slammed with all day long and break down what do you need, what are you looking for, what are your options? And then you make an educated decision on it.

SPEAKER_01 12:50

Yeah, there is definitely no shortage of marketing out there. A ton of it. And again, nonstop, it just flows.

SPEAKER_02 12:55

And there's motivation. All of this is money motivated, right? So uh you know, every one of these things is the end all be all, and you need to do it. And I feel bad for people because they are flooded and overwhelmed and they don't even know how to negotiate the system, and they've been convinced by somebody that this is what you need to do. And again, it's really important to go back to the basics. And if you feel like you go into a provider or you see a surgeon and they're like, okay, that's it. That's the one thing, you know, in there, you you know, ask questions, figure out what's going on, see if there's a fit on both sides of it.

SPEAKER_01 13:30

Dr. Sanderson, great information. Thank you so much for being here today. If you enjoyed the show, make sure you click or subscribe below to follow us for so you don't miss miss the next episode. Thank you for joining us today for Vitality Unfiltered.

SPEAKER_00 13:42

Thanks for joining us on Vitality Unfiltered with David Bowder. Addressing norms, busting myths, and uncovering health realities for a more vibrant life today. For more expert insights and real talk, make sure to subscribe and join us next time.