Handling Basics Helps Prevent Unhappy Patients

VAIL, COLO. — Efforts by cosmetic surgeons to filter out potentially troublesome patients and rein in their own desire to "fit the operation to the patient" during preoperative consultations can help to avoid unexpected postoperative quagmires, Dr. Jonathan M. Sykes said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Media exploitation of cosmetic surgery on television shows such as "Extreme Makeover" tends to trivialize the healing process, bypass typical recovery issues, and create a tacit acceptance of the "megaprocedure" without showing the patients as being involved in the decision-making process, said Dr. Sykes, professor of otolaryngology and director of facial plastic surgery at the University of California, Davis.

"We even say at these meetings, 'The patient needed a chin implant.' I've never seen a person who'd die [without] a chin implant or a facelift," Dr. Sykes said. "But we get into that mentality of thinking they need something and in fact they don't. When we think that way, our staff thinks that way, and our patients can think that we think that way."

When it is difficult to judge a patient's nature and how he or she will react to the results of surgery during the preoperative consult, it may be best to only perform a single, reversible procedure or decline to operate on the patient, he advised.

"Our consultations are different from almost every other consultation in medicine. Most people who go into a surgeon's office want the surgeon to say, 'You don't need surgery.' Our patients want us to say, 'You need this.' They are all a little insecure or are insecure people to start with, in general," he said.

The Correct Patient

The criteria for a successful outcome include a carefully selected, highly motivated patient. Good candidates for cosmetic surgery are people with a positive self-image who are easy to communicate with, are friendly to staff, and have reasonable expectations. Unsuitable candidates may be overdemanding, uncooperative, narcissistic, or litigious.

Others may have a poor self-image, body dysmorphic disorder, or prior psychiatric disorders, or they may express criticism of other physicians.

Candidates who have body dysmorphic disorder often ask at the end of their procedure, "When can I have my next operation?" Dr. Sykes said. These patients may be embarrassed by their desires and hide their true wants.

Surgeons will rarely be disappointed that they did not operate on someone, Dr. Sykes said. At the end of the year, surgeons might have a few people that they wish they had not operated on, but they won't know if any great patients were missed.

The biggest factor that affects postoperative appearance is not the surgeon's work but the patient's preoperative appearance. Other influencing factors are the choice of procedure, the execution of the surgery, and patient healing. "The happy patients really aren't necessarily the people with the best results," he said. Some people have good results but aren't necessarily happy. The patients' own perceptions will determine how they view their postoperative appearance.

The Correct Procedure

It is important to discuss and document which things are most important to patients because they may come back to complain about one small thing out of many things that were done during a surgical session, claiming that the small thing was actually what they most wanted. Dr. Sykes sometimes leaves the room for a few minutes and lets patients think about a list of the things that they would like to change, but not how they would like to change them. They give him the list in order of importance, and he includes it in their records.

By helping to choose the procedure(s), patients will be more vested in their decision because they think it is theirs and will be less likely to become angry if complications arise or they are unhappy with the result.

While going through this process, use a procedure-oriented approach with patients instead of a problem-oriented approach to diagnose what they need. "Fit the patient to the operation and not the operation to the patient," he advised.

A machine that is bought initially for a particular procedure may end up being used on patients who don't necessarily need the procedure, even though another procedure may be more appropriate. This is similar to the tendency to suggest only certain procedures to patients because of the surgeon's familiarity or comfort level with them, Dr. Sykes said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.