This article reviews some basic principles of patient selection for facial plastic surgery. There are patients who are not good candidates, independent of the deformity and the ability of the surgeon. Reasons include subtle and not so subtle psychiatric disorders, unrealistic expectations, lack of communication despite multiple visits, and litigious patients. Complications or suboptimal results are not well handled in these patients and often produce an uncomfortable experience for the surgeon and staff in the postoperative period. These patients are best avoided or should be provided a much longer evaluation period prior to any surgery.
Key points
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The axiom that “the surgeon makes his/her living from the patients on whom he operates while he makes his reputation from those he refuses to operate” is very true, but is hard to do.
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Patients who are easy to reject for surgical procedures include:
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Other surgeons’ complications
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Litigious patients
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Patients the surgeon or his or staff do not like
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Patients with a psychiatric disorder
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Patients with a body dysmorphic disorder
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Patients with multiple medical comorbidities
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Patients who are difficult to evaluate for selecting for surgical procedures, include, among others:
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Depressed patients
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Minor deformity patients
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Doctor shoppers
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Patients who have had several plastic surgery procedures by others
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Super fastidious patient
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Family members and close friends
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Heavy smokers
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Chronic pain patients on daily pain medications
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Introduction
The procedure is over. The surgeon performed it as well as possible, but there is a complication. How to deal with the complication and how it might have been avoided is the purpose of this issue of Facial Plastic Surgery Clinics of North America . There is another important consideration, which is the purpose of this article: how will the patient deal with the fact that a complication or untoward result has occurred, and what will be the effect on the doctor–patient relationship? No patient or surgeon is happy about a complication, and fortunately they are uncommon. However, the patient was not expecting a complication, even though he or she had been informed that it was possible. Informed consent should be detailed and in writing!
It may not be a true complication, but the result is not what the patient (or surgeon) expected. Or perhaps the result is about what the surgeon anticipated but not the patient, a difference in expectations. There is a difference between a true postoperative complication, such as an hematoma or wound infection, and a result that does not meet the patient’s expectations.
The latter is more difficult for the surgeon to deal with, because it may be presumed to be caused by the surgeon who did not perform the operation adequately. An infection is not perceived as being caused by the surgeon, whereas a nose that still has some deviation following rhinoplasty or a wide facial scar following a facelift may be perceived as the surgeon’s fault.
In addition, the patient’s anguish will also depend in part on how easy it will be to fix the problem. A minor office procedure under local anesthesia is a much more acceptable solution than a second procedure under general anesthetic, independent of cost.
The end result is the same, an unhappy patient who wants the surgeon to fix the problem, sooner rather than later. Also in the mix are the questions: “Why did this happen to me?” and “If I had known this would have been the result, I would have never have had the surgery!” And to further compound this issue, what about the case where the surgeon feels the result is good, and the patient does not? Too often, this is the time that the surgeon first realizes he/she has chosen the wrong patient in regard to dealing with an unexpected result.
There are patients who will definitely benefit from facial plastic procedures. They want them done and will pay the surgeon to do so.
But the surgeon should not. Certain patients are easy to pick out as bad psychologic candidates for cosmetic procedures, and I will briefly discuss them. More important are those who are not easy to pick out and reject. This article spends more time on this latter group. The axiom that “the surgeon makes his/her living from the patients on whom he operates while he makes his reputation from those he refuses to operate” is very true, but is hard to do.
Most surgeons have strong egos and are optimistic; they expect to get a good result, and that should produce a happy patient, even in patients who show some signs that they should be rejected as candidates. There is no foolproof method, but experience will provide wisdom on the subject; wisdom is often painfully acquired. Recognizing these patients prior to surgery is an art that must be learned the same as how to do a facelift. But this is only the first part; one must act upon intuition and not do the case. This is harder, particularly in the early years of practice when the economics are extremely important, and a surgeon’s rules about on whom not to operate are less defined. Once a medical malpractice suit is filed, the state medical board is asked to suspend the surgeon’s license by a patient, or a Web page describes to all what a terrible surgeon one is. The surgeon then will look back and wonder “Should I have seen this coming?”
In addition to over 4 decades of practice, I have benefited from many years as an expert reviewer for the California Medical Board, as well as reviewing some 50 cases of alleged facial plastic surgery medical malpractice for attorneys. So, not only do I have my own experiences in poor patient selection, I have been exposed to those of other surgeons.
Before starting on the categories of patients on whom not to perform surgery, there are some techniques that can help one learn more about patients:
Computer imaging
Computer imaging not only helps make sure the surgeon knows what the patient wants from the surgery but also shows the patient what can realistically be accomplished. It provides another benefit, additional meeting time that allows one to better know the patient prior to any surgery. There are 2 caveats. First, the surgeon must make sure he or she can accomplish the modifications of facial appearance that one provided on the computer-generated images. One should not make it so perfect that the patients’ expectations are too high. Second, surgeons are experts in sculpting in flesh but may not be so good when drawing a computer image. If the surgeon does not possess this skill, he or she should learn how to do it or do it outside the presence of the patient and provide it later.
Patients do not like to see their surgeon make a mistake and erase it; I think they worry that a similar error may occur during surgery, and they know that if that happens, it cannot be erased it as it was on the computer images.
Discuss policies regarding fees for revision surgery up front
One’s policy on this important matter must be clearly stated to the patient prior to any surgical procedure, preferably in writing. It can be anything the surgeon thinks is fair. Make sure that there is agreement on what is a postoperative result that needs fixing. I tell them we both have to agree that there is a problem following surgery that needs to be fixed and that I am able to fix it. This addresses the point that I must agree there is something that needs to be done, not just the patient. I do not charge a surgical fee for revisions but tell the patient they will have to pay for the use of an operating room and anesthesia, if required. This helps eliminate any “I am not paying for your mistakes” conversations.
Introduction
The procedure is over. The surgeon performed it as well as possible, but there is a complication. How to deal with the complication and how it might have been avoided is the purpose of this issue of Facial Plastic Surgery Clinics of North America . There is another important consideration, which is the purpose of this article: how will the patient deal with the fact that a complication or untoward result has occurred, and what will be the effect on the doctor–patient relationship? No patient or surgeon is happy about a complication, and fortunately they are uncommon. However, the patient was not expecting a complication, even though he or she had been informed that it was possible. Informed consent should be detailed and in writing!
It may not be a true complication, but the result is not what the patient (or surgeon) expected. Or perhaps the result is about what the surgeon anticipated but not the patient, a difference in expectations. There is a difference between a true postoperative complication, such as an hematoma or wound infection, and a result that does not meet the patient’s expectations.
The latter is more difficult for the surgeon to deal with, because it may be presumed to be caused by the surgeon who did not perform the operation adequately. An infection is not perceived as being caused by the surgeon, whereas a nose that still has some deviation following rhinoplasty or a wide facial scar following a facelift may be perceived as the surgeon’s fault.
In addition, the patient’s anguish will also depend in part on how easy it will be to fix the problem. A minor office procedure under local anesthesia is a much more acceptable solution than a second procedure under general anesthetic, independent of cost.
The end result is the same, an unhappy patient who wants the surgeon to fix the problem, sooner rather than later. Also in the mix are the questions: “Why did this happen to me?” and “If I had known this would have been the result, I would have never have had the surgery!” And to further compound this issue, what about the case where the surgeon feels the result is good, and the patient does not? Too often, this is the time that the surgeon first realizes he/she has chosen the wrong patient in regard to dealing with an unexpected result.
There are patients who will definitely benefit from facial plastic procedures. They want them done and will pay the surgeon to do so.
But the surgeon should not. Certain patients are easy to pick out as bad psychologic candidates for cosmetic procedures, and I will briefly discuss them. More important are those who are not easy to pick out and reject. This article spends more time on this latter group. The axiom that “the surgeon makes his/her living from the patients on whom he operates while he makes his reputation from those he refuses to operate” is very true, but is hard to do.
Most surgeons have strong egos and are optimistic; they expect to get a good result, and that should produce a happy patient, even in patients who show some signs that they should be rejected as candidates. There is no foolproof method, but experience will provide wisdom on the subject; wisdom is often painfully acquired. Recognizing these patients prior to surgery is an art that must be learned the same as how to do a facelift. But this is only the first part; one must act upon intuition and not do the case. This is harder, particularly in the early years of practice when the economics are extremely important, and a surgeon’s rules about on whom not to operate are less defined. Once a medical malpractice suit is filed, the state medical board is asked to suspend the surgeon’s license by a patient, or a Web page describes to all what a terrible surgeon one is. The surgeon then will look back and wonder “Should I have seen this coming?”
In addition to over 4 decades of practice, I have benefited from many years as an expert reviewer for the California Medical Board, as well as reviewing some 50 cases of alleged facial plastic surgery medical malpractice for attorneys. So, not only do I have my own experiences in poor patient selection, I have been exposed to those of other surgeons.
Before starting on the categories of patients on whom not to perform surgery, there are some techniques that can help one learn more about patients:
Computer imaging
Computer imaging not only helps make sure the surgeon knows what the patient wants from the surgery but also shows the patient what can realistically be accomplished. It provides another benefit, additional meeting time that allows one to better know the patient prior to any surgery. There are 2 caveats. First, the surgeon must make sure he or she can accomplish the modifications of facial appearance that one provided on the computer-generated images. One should not make it so perfect that the patients’ expectations are too high. Second, surgeons are experts in sculpting in flesh but may not be so good when drawing a computer image. If the surgeon does not possess this skill, he or she should learn how to do it or do it outside the presence of the patient and provide it later.
Patients do not like to see their surgeon make a mistake and erase it; I think they worry that a similar error may occur during surgery, and they know that if that happens, it cannot be erased it as it was on the computer images.
Discuss policies regarding fees for revision surgery up front
One’s policy on this important matter must be clearly stated to the patient prior to any surgical procedure, preferably in writing. It can be anything the surgeon thinks is fair. Make sure that there is agreement on what is a postoperative result that needs fixing. I tell them we both have to agree that there is a problem following surgery that needs to be fixed and that I am able to fix it. This addresses the point that I must agree there is something that needs to be done, not just the patient. I do not charge a surgical fee for revisions but tell the patient they will have to pay for the use of an operating room and anesthesia, if required. This helps eliminate any “I am not paying for your mistakes” conversations.
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