1. The Aesthetic Surgery Patient
Senior Author Tip:
Cosmetic surgery is elective and rarely addresses medical conditions, but it restores or improves physical features that are concerning to patients. Although the request for aesthetic surgery is most commonly associated with aging, some patients seek improvement of normal anatomic structures to enhance their appearance.
Demographics and Statistics
Interest in cosmetic procedures continues to increase with over $15 million spent annually in the United States for combined surgical and nonsurgical procedures.
91% are women, and 9% are men.
Approximately 25% of cosmetic patients are minorities.
Approximately 40% of cosmetic patients are 35–55 years of age.
Approximately 50% of patients have multiple procedures.
>50% of patients who have a cosmetic procedure will return for another one.
47% of patients have multiple procedures performed simultaneously.
Role of the Aesthetic Surgeon
Is a physician first and an aesthetic surgeon second
Acts as a physician, therapist, and artist:
Physician: Evaluates the patient to determine surgical feasibility and medical fitness
Therapist: Recognizes psychology that may be amplified by surgery
Artist: Considers aesthetic objectives. Will not go against aesthetic sense
Must have a clear understanding of patient’s motivation and expectations before surgery
Ultimately concerned with the patient’s welfare
An experienced aesthetic surgeon should be able to recognize body dysmorphic disorder and severe depression. Many patients seeking aesthetic surgery are excellent candidates and do well postoperatively despite taking antidepressants. 3
A well-informed patient is a happy patient.
Patient Characteristics
The shopper: Consults several surgeons before making decision, compares factors such as prices, staff, availability, reputation, website, and online reputation
The talker: Takes considerable time during consultation and may have many questions about multiple problems
The planner: Has already decided exactly what he or she wants and is looking to see if surgeon can do it
The listener: Does not talk much and wants surgeon to explain everything and make the decisions
Patient Consultation
Introduction and First Impression
Patients may be nervous and insecure about their appearance.
Personal conversation at the beginning of the consultation helps to relax patients and establish rapport.
The surgeon should begin immediately assessing the patient’s general appearance, demeanor, and behavior during the initial interaction.
The initial introduction should also establish why the patient is there to see the surgeon and what their aesthetic concerns are.
Psychological and physical evaluation begins with the first impression. 4
Senior Author Tip:
Today most patients come in for a consultation having researched on the Internet and most likely consulted with other physicians. After an introduction and “small talk” designed to put patients at ease, I will ask how much they know about the procedure they are interested in. After they respond, I will add that I will provide them all the information I feel is important in making a decision.
Health History
Baseline health, comorbidities, tobacco use, prior surgeries, and prior pregnancies are determined.
Surgical risk is carefully assessed based on medical history and desired procedure.
Health criteria for aesthetic surgery should be at least as stringent as those for reconstructive cases because of the strictly elective nature.
Surgery may be deemed inappropriate for unhealthy patients and those with a high risk of complications.
Senior Author Tip:
Patients often ask me if they are too old for a facelift. I tell them there is no such thing as “too old for a procedure”; it is not age that counts but general health. The question should be, “Am I healthy enough for a facelift?” I am also asked, “Am I too young for a facelift.” My answer is that there is no set age. If I think the patient will see an improvement, I will recommend a facelift regardless of age
Senior Author Tip:
I find some patients are not always forthcoming about health issues for fear of being turned down. For facial rejuvenation, I usually ask about smoking history. If they say, “I do not smoke,” I will ask if they ever have in the past and, if so, for how long and how heavily. I repeatedly ask about high blood pressure, because I believe untreated and or unrecognized hypertension is the major contributing factor to hematoma after facial rejuvenation. When patients are asked about prior surgery, most may not list cosmetic surgery. I specifically ask every patient if they had previous aesthetic procedures
Psychological Evaluation
A significant proportion of patients desiring cosmetic surgery may have some psychopathology.
Cosmetic surgery may improve symptoms in some patients with psychological conditions like depression or neurosis.
Certain groups consistently are shown to do poorly after aesthetic procedures.
Aesthetic surgeons should be able to identify psychologically unfit patients and make suitable recommendations. 5 Psychiatric consultation should be obtained when appropriate.
Aesthetic surgeons determine how closely a patient’s self-image matches the true image and decide if the patient’s self-image can be improved with surgery performed on the true image. 6
Senior Author Tip:
I like to determine the motivation behind the desire for surgery. Is the patient doing this for himself or herself? Are there hidden agendas such as saving a failing marriage, wishing to please a partner or parent? I advise my patients they should do it for themselves and not for anyone else. An otherwise excellent surgical result may lead to patient disappointment if it does not meet the hidden agenda. A more youthful face or shapely body may not save a failing marriage or push a boyfriend or girlfriend into a proposal. Why patients seek a procedure and who they are trying to please may not always be readily apparent, but it is important for surgeons to know
Psychological Indicators
Positive indicators (green light)
Patient has anatomic flaw that is visible to both the patient and the surgeon.
Patient is not preoccupied with flaw and has been planning cosmetic surgery for a long time.
Patient generally feels good about himself or herself, is aging, and wants to look younger.
Negative indicators (red flags)
Patient complains of anatomic flaws that the aesthetic surgeon does not perceive.
Patient is attempting to fix a social problem by surgically correcting appearance.
Patient impulsively decided on cosmetic surgery and has considered it for only a brief period of time.
Patient had multiple cosmetic procedures and is always dissatisfied with the results.
Patient has excessively “shopped” for surgeons. Patients who are still uncertain after meeting with three or more surgeons are often difficult and unhappy after surgery.
Patient is being treated for multiple psychiatric illnesses and/or history of numerous psychiatric admissions.
Motivation
Intensity of motivation positively correlates with satisfaction and shorter recovery and negatively correlates with postoperative pain.
Patients seeking cosmetic surgery are motivated by internal or external pressures.
Patients with internal motives are generally better candidates than those with external motives.
Patients with internal motives desire change for themselves and usually feel vulnerable about deficits in appearance and a commitment to physical change.
Psychological state is secondary to a definite physical defect. Correction of the defect alleviates the anxiety.
Perceived physical deficit may not be easy to discern from genuine deficit.
CAUTION: If a perceived deficit is a major focus and is out of proportion with the genuine deficit, then the patient may find another focus to channel anxiety after surgical correction.
Patients with external motives seek to please others who think that physical change will result in a social change (e.g., improve a relationship, save a marriage, advance a career).
Social goals are often not met, resulting in dissatisfaction with surgery.
May be pressured into the procedure and passive about surgery
Motivation levels are weaker if not also driven internally and may indicate a more difficult postoperative course.
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