How SAFA Helps Doctors Prevent Errors: A Real Case from My Expert Practice

An error in aesthetic medicine can begin long before a procedure — when the cause of the patient’s concern is incorrectly identified.

Facial asymmetry, a pronounced fold or a change in facial contour can have different causes. Before recommending correction, the doctor needs to understand which structures contribute to the concern and what the proposed intervention can actually change.

For this purpose, I created SAFA — Standardized Aesthetic Facial Assessment, my structured system for aesthetic facial assessment. Its purpose is to help doctors identify findings systematically, classify them, explain them to patients and use them when choosing a treatment plan.

A Real Case from My Expert Practice

I was asked to examine a patient and provide an expert opinion on whether thread correction had been appropriate for her facial asymmetry. This account is anonymised and shared with the patient’s consent.

The patient initially consulted a doctor about facial asymmetry. She underwent a thread lift, after which the asymmetry became more pronounced.

The doctor inserted additional threads without charge, but this did not resolve the problem. Dissatisfied with the result, the patient requested removal of the threads.

The doctor was concerned about the pain and tissue trauma associated with removal and referred her to a plastic surgeon. The patient subsequently underwent extensive surgery under general anaesthesia, which left a significant facial scar.

She sought a refund for the original treatment, reimbursement of the subsequent surgical costs and compensation for physical and psychological harm.

During my examination, I identified a skeletal component to the asymmetry that had not been recognised in the initial assessment.

My expert conclusion was that threads could not correct her underlying asymmetry in this particular case.

The doctor should have identified and documented this finding, discussed it with the patient and explained why the proposed procedure could not address her principal concern. This could have changed the initial plan: declining thread correction of that asymmetry and, where appropriate, referring her to a relevant specialist.

Asymmetry Is a Finding: Its Cause Must Be Established

The term “asymmetry” describes a difference between the two sides of the face. It does not, by itself, explain the cause.

In my assessment, I distinguish several possible components:

• Skeletal: differences in the structure and support of the facial skeleton.
• Soft tissue: differences in the volume, distribution and position of soft tissues.
• Dynamic: differences associated with muscular activity and facial expression.
• Combined: a combination of several causes.

Similar-looking concerns may require different decisions. Before selecting a procedure, the doctor must establish which structures contribute to the asymmetry and whether the method can deliver the change the patient expects.

A skeletal component does not mean that every patient requires surgery. It means that the doctor must take this finding into account, explain the limitations of the proposed correction and determine whether further assessment or specialist consultation is needed.

Findings Must Influence the Treatment Plan

Writing “facial asymmetry” in the medical record is not enough. The suspected cause, its clinical significance and its effect on treatment selection should also be documented.

In this case, the patient should have been told that threads act on soft tissues but do not correct the skeletal cause of her underlying asymmetry. Promising to eliminate that asymmetry with threads would therefore have been unjustified.

This is where assessment becomes the foundation of a clinical decision. The doctor first establishes the nature of the problem, then chooses an appropriate course — including the option of declining an intervention.

SAFA helps organise this sequence and connect findings with the treatment plan.

An Unsatisfactory Result Requires Reassessment

If asymmetry becomes more pronounced after a procedure, the doctor needs to revisit the initial assessment:

• Was the cause of the concern correctly identified?
• Was the selected procedure appropriate for that cause?
• What changes occurred after the intervention?
• Is there a clinical basis for further correction using the same method?

Offering an additional intervention without charge does not establish its clinical justification.

The wish to help a dissatisfied patient is understandable. However, another intervention needs a fresh assessment and a clear objective. Depending on the circumstances, the appropriate next step may be observation, further investigation or referral to another specialist.

Patients Must Understand the Findings and Limitations

I regard discussion of assessment findings as an essential part of treatment planning.

The doctor should explain:

• what findings have been identified;
• the suspected cause of the patient’s concern;
• what the proposed procedure can change;
• which features will remain;
• the risks and alternatives;
• why declining a procedure may be reasonable in that particular case.

A meaningful discussion helps patients make decisions with an understanding of their anatomy and the possibilities of treatment.

Aligning expectations is particularly important when asymmetry is present before treatment. The patient and doctor should share a clear understanding of what is being corrected and what limitations apply.

The Clinical and Medico-Legal Value of SAFA

Systematic assessment provides a foundation for better-reasoned decisions and clear documentation.

The medical record should reflect the initial findings, the reasons for selecting treatment, the agreed objective, the limitations discussed and the changes observed after the intervention. Standardised photographs and reassessment help compare the initial condition with the outcome.

If a dispute arises, this documentation can help reconstruct the clinical decision-making process: what the doctor identified, what was explained to the patient, why a particular method was proposed and how the doctor responded when a problem developed.

Documentation, however, does not replace appropriate treatment selection. An identified finding must genuinely influence the doctor’s decision.

SAFA does not guarantee freedom from complications, complaints or litigation. Its practical value lies in organising assessment, clinical reasoning and communication with the patient. Legal responsibility is determined separately, according to the circumstances of the individual case.

What I Want Doctors to Learn

In SAFA training, I place particular emphasis on this sequence:

Assess → classify → establish priorities → explain to the patient → choose a plan → reassess the outcome.

Doctors should be able to distinguish between the causes of similar-looking concerns, understand the capabilities and limitations of different methods and reconsider an initial decision when the outcome does not meet expectations.

This case illustrates how serious the consequences of overlooking the cause of asymmetry can be. A single clinical case does not, by itself, demonstrate that SAFA reduces errors or legal claims; those outcomes require separate research.

My aim is to teach doctors to base their decisions on a systematic assessment of the patient.

Before offering correction, establish the cause of the concern and explain whether the chosen method can address it.