When the right answer is to do nothing yet

Someone asks for jawline filler when what has changed is skin laxity, and adding weight to a lax envelope pulls it down.

In each case the honest answer is that we can perform the requested treatment and it will not do the requested thing. That conversation takes twenty minutes and saves a year.

This has to be put carefully, and it is not a diagnosis to be made in a cosmetic consultation. But there is a recognisable pattern: distress that is severe relative to a finding that is minimal or invisible to others, hours a day spent checking, a history of several procedures none of which brought any relief, and a conviction that one more will.

Treating that reliably makes it worse. The right response is a frank, non-judgemental conversation and an offer to help find appropriate support, which is not us with a syringe. We would rather lose the booking than take it.

Filler assessed at four weeks is being assessed through residual swelling and incomplete integration, and adding more at that point is chasing a moving picture. It is how faces become overfilled without anyone intending it. A neuromodulator repeated at eight weeks because the frown flickered shortens the interval for no benefit and raises the theoretical antibody risk. Laser sessions squeezed closer together do not respect the growth cycle and simply waste a session.

Injectables are not performed in pregnancy or while breastfeeding. Not because harm has been demonstrated, but because it has not been studied and there is no version of this treatment that is urgent. Retinoids are out. Some skin treatments remain entirely appropriate, and we will say which.

Bruising can take ten days to resolve and a neuromodulator is not fully settled until day fourteen. So: nothing injectable within three weeks of a wedding, a photograph or anything else that cannot be moved, and nothing new at all before an event, ever. The first time you have a treatment is not the occasion on which to discover how you bruise.

• Active skin infection, or a cold sore, in or near the treatment area.
• An autoimmune condition that is currently active, or a recent change in immunosuppressive treatment.
• Anticoagulation, without input from the prescribing physician.
• Isotretinoin currently or recently, for resurfacing and laser.
• A vaccination in the previous two weeks, for filler specifically, where delayed inflammatory reactions have been reported.
• Any skin lesion that has not been identified. That gets assessed before anything is treated around it.

It is not a brush-off, and it should never feel like one. A consultation that ends without treatment should still end with something written down: what we found, what we would do and in what order, what has to happen first, what you should be doing at home in the meantime, and a date to review it.

If you leave with none of that, you were not declined for a clinical reason. You were simply not sold anything, which is a different and much less useful outcome.

The clinics that treat everybody who asks are easy to find. It is the least interesting way to run a practice, and the results of it are recognisable at a glance.