Which Treatment Do I Actually Need?

Most people arrive at this practice asking for a treatment, and the more useful question is almost always what the concern actually needs.

Those are different conversations. The first one ends with a booking. The second one sometimes ends with me telling you that the thing you came in for is not the thing that will help, which is a worse afternoon commercially and a better one for you.

I own this practice and we sell everything mentioned below, so weigh what follows accordingly. I would make the same argument about a competitor’s consultation, which is roughly the point.

Where should I start?

With a consultation, and with a physician. Dr. Raneiro or I will sit with you, look at your skin properly, ask what is actually bothering you rather than what you have read about, and give you a plan. Consultations are complimentary, with one exception I will come to.

Nothing gets treated that day unless you want it to. Some people book a consultation and a treatment together because they already know what they want and they are probably right. Others leave with a written sequence and start in a month. Both are fine, and the only version I would push back on is the one where you book a treatment you chose from an Instagram post without anyone having looked at your face.

Why does a physician do the consultation?

Because the range of things we can offer is wide enough that the first question can honestly be what your concern needs, rather than which of the two or three treatments on our menu can be pointed at it.

That range runs from routine skincare and maintenance, through facials and peels, through lasers, through injectables, through energy-based devices, to physician-led medical care. A practice that only owns a laser will find a reason to use the laser. A practice that only does injectables will describe your problem in terms of volume. Neither of them is being dishonest; they are answering the question they are equipped to answer.

The single most useful sentence I can give you about this practice is that the recommendation is not limited by what we sell. It is checkable rather than a matter of taste, and the rest of this article is the evidence for it.

What stops you recommending the most expensive thing?

Nobody here is paid on treatment sales. Not the physicians, not our advanced practice nurse, not the aestheticians. The physicians and the APN accept no tips either.

I am aware that every practice says some version of this, so here is why it is structural rather than a claim about our characters. Commission changes what gets recommended at the margin, and the margin is exactly where these decisions live — the patient who could reasonably have three sessions or six, the one for whom a peel and a laser would both help somewhat. Remove the incentive and those calls get made on the merits, because there is nothing else for them to be made on.

What if the answer is not something you sell?

Then we say so and we refer you.

The clearest example sits on our filler page. Under-eye hollowing is one of the most requested treatments in aesthetics, and whether filler suits you there is an anatomy question rather than a preference. Where the tear trough is genuinely hollow, filler works well. Where the skin is thin and crepey rather than empty, platelet-rich fibrin is usually the better tool. And where the actual problem is skin excess or a true lower-eyelid fat pad, neither one fixes it — that is an oculoplastic evaluation, usually at Wills Eye Institute or the oculoplastic service at Penn, and we refer rather than camouflaging a surgical problem with product.

The same logic applies across the practice. Surgical laxity goes to a plastic or facial plastic surgeon. A suspicious lesion goes to dermatology. Venous disease gets a duplex ultrasound and a vein specialist before anyone injects anything. Advanced or scarring hair loss goes to a transplant surgeon. None of that is generosity — a referral that should have happened and did not is the kind of mistake that follows a practice around.

What do you refuse to do?

Liquid rhinoplasty is the one that costs us the most bookings, and it is worth explaining because it shows how the reasoning works.

Fact vs. Fad: non-surgical nose reshaping is marketed as a fifteen-minute alternative to surgery, and the American Society for Dermatologic Surgery’s task force on filler complications puts the nose first on its list of high-risk zones for vascular occlusion and blindness, ahead of the glabella and forehead. The nose is also the site most frequently implicated in published cases of filler-associated vision loss. Those are proportions of reported cases rather than a rate, and nobody has published a reliable incidence for the nose specifically, so I am not going to give you a number that does not exist. Two further things are true and rarely mentioned in the marketing: injecting filler into the nose is not an FDA-approved use of any dermal filler, and the FDA specifically recommends against it. Off-label use is lawful and routine in medicine, and it is still something you deserve to be told before rather than after.

We decline it. The filler page sets out the reasoning in full. Plenty of good clinics offer it; we think the risk-to-benefit is wrong for a cosmetic change that surgery achieves permanently, and saying so out loud is more useful to you than taking the appointment.

The list is longer than one item. We do not inject hip joints with platelet-rich plasma, because we cannot image the joint and placing it blind is not good medicine. We do not offer sclerotherapy, and we say plainly what we do instead. And we decline peptide therapy outright, with a page explaining why and a Journal article going through the evidence compound by compound.

Who actually treats me?

The provider you choose at booking, every time, with no substitutions.

For injectables, regenerative procedures and microneedling, that is Dr. Raneiro or me — unless you select Martha Villarin, our advanced practice nurse and a partner in the practice, at booking. Laser hair removal and facials are performed by our licensed medical aestheticians, Carla and Jennifer, who are very good at them and who I would not ask to do my injecting any more than they would ask me to do their extractions.

Where it adds precision, injections are placed under handheld ultrasound, which shows your anatomy rather than the average anatomy in a textbook diagram. Hyaluronidase, the enzyme that reverses hyaluronic acid filler, is kept on site, and a physician who can recognize a vascular occlusion is in the building rather than reachable by phone.

What does a plan actually look like?

Sequenced, and usually longer than people expect.

Skin has an order of operations. Active inflammatory acne gets treated before anyone resurfaces anything. Pigment is easier to chase in the autumn and winter than in July. Collagen remodeling from a device shows up over months, not days, so the sequence has to be built backward from whatever date matters to you — which is the entire premise of our wedding and event consultation, the one consultation that carries a fee, and it is credited toward your plan.

A good plan also has maintenance in it, honestly labeled. A HydraFacial is maintenance and we say so on the page; it is not going to fix acne scarring, and how long it lasts is a question we answer with our own observation rather than a study, because no study has measured it.

Is this the same thing as your concierge membership?

No. Concierge primary care is a separate medical membership with its own panel and its own terms. Everything in this article is how we work with every patient who walks in, member or not, and none of it sits behind a fee.

A meaningful share of our patients are physicians and their families, some of whom drive here from Delaware. I mention it because it is the hardest signal in aesthetics to fabricate, and because colleagues tend to ask better questions than our marketing does.

So what should I book?

A consultation, and then whatever the two of us decide in it.

If you already know exactly what you want and you have had it before, book the treatment and choose your provider. If you are looking at your face and cannot name what is bothering you, that is not a failure of vocabulary — it is the normal case, and it is what the appointment is for.

References

Jones DH, Fitzgerald R, Cox SE, Butterwick K, Murad MH, Humphrey S, Carruthers J, Dayan SH, Donofrio L, Solish N, Yee GJ, Alam M. Preventing and treating adverse events of injectable fillers: evidence-based recommendations from the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatologic Surgery. 2021;47(2):214–226. doi:10.1097/DSS.0000000000002921 (professional-society evidence-based guideline. “In order of risk, the nose, glabella, forehead, superior nasolabial fold, and medial cheek are considered high-risk zones for vascular occlusion and blindness”)

Doyon VC, Liu C, Fitzgerald R, Humphrey S, Jones D, Carruthers JDA, Beleznay K. Update on blindness from filler: review of prognostic factors, management approaches, and a century of published cases. Aesthetic Surgery Journal. 2024;44(10):1091–1104. doi:10.1093/asj/sjae091 (systematic review of published case reports, 511 cumulative cases 1906–2023; nose 40.6% of cases. A proportion of reported cases, not an incidence rate — there is no denominator)

United States Food and Drug Administration. Dermal fillers (soft tissue fillers). fda.gov (lists injection of the nose under “Unapproved Uses of Dermal Fillers” and recommends against it; approved indications do not include nasal augmentation. Note that “nasolabial folds” is an approved indication and is the cheek-to-mouth crease, not the nose)