Introduction

Psychological Considerations

Excellent communication between the patient and physician is a key component for good medical practice. When communication is lacking, conflicts arise that can create a tipping point for future legal complaints. Thus, it is important to focus on the psychological dimension — which includes (1) the patient’s understanding of his/her health condition, (2) the patient’s understanding of the implications of the different treatment alternatives, and (3) the psychological support that the patient will need during the process — when we choose patients eligible for surgeries like breast reconstruction, as such surgeries are closely linked to legal issues [20].

Considering medical malpractice, it is of vital importance to pay special attention to patients who have not obtained their expected outcomes after they have been injected with liquid silicones and are now in need of more complex procedures to treat sequelae. Therefore, the first responsibility for plastic surgery specialists, from an ethical perspective, is to clarify the risks, even at the expense of the patient leaving. An equal balance between the patient’s overexaggerated expectations and his/her current reality will allow for a good course of action and the achievement of good results. Given this scenario, it is key not to be pressured by patients’ anxiety, since it is the specialist who must decide whether or not each patient has access to the treatment. It is better to say “no,” than to have dissatisfaction and possible complaints later. If the treatments requested by the patient are not recommended by the specialist, he or she should not accept requests that sooner or later will end in patient dissatisfaction.

It is important to remember that medicine has not only advanced rapidly in recent times, but it also has questioned its practices in several areas as well. The shadow of medical malpractice is real and latent in every single act of a physician. It is relevant and cannot be denied or ignored due to physicians’ fear or pride.

On many occasions, it is difficult to define what good practice is and how much one could deviate from it or not adhere to that definition for it to be considered wrong. Good medical practice can be defined to include a good decision-making process, medical actions that comply with expert standards, attitudes that satisfy patients’ expectations, compliance with the law, the correct management of resources for the medical act, and the correct disclosure of information to patients.

Plastic surgery for aesthetic purposes, considering its psychosocial connotations, has a higher probability of malpractice claims, if it is not practiced according to lex artis. However, regardless of good technique, the existence of conflicting patients can convert an excellent outcome into a deficient one. Therefore, it is very important to take precautions and detect those patients who might become problematic in the future [6].

Some authors have dealt with the topic, and their writings deserve a detailed analysis.

Renè Girard, a philosopher and writer, provided a phenomenological vision that established a typology called the “desire of the other.” This hypothesis claims that the asserted absolute and natural individualistic autonomy of human desire is a fallacy. Some people do not want or desire something for themselves, but for another person, because of the other’s desires or wants. Thus, a third party appears, on which the value of the desire depends. In this way, a patient goes for a consultation and believes that he or she, through his or her own desire, needs aesthetic treatment with silicone injections into the breasts when, in fact, they may be influenced by the desires of another person. Once the surgery has been performed, dissatisfaction may appear even with excellent results [16].

Many articles have been written, with special reference to conflicting and problematic patients, stressing the importance of psychological considerations. Certain characteristics of patients’ personality, especially pertaining to their ability to adapt to an intervention and, especially, the result, deserve careful study before moving forward with aesthetic surgery (see Chaps. 17 and 18).

According to Giacomantone and Mejía [15], patients with a “normal” reaction to surgery will experience good recovery 96 percent of the time, while someone who has a “paranoid” reaction is ten times more likely to inadequately accept the surgical intervention. Although his statement refers to surgeries in general, it can be inferred that there would be similar outcome associations among patients likely to request treatment for siliconomas, which might require a mastectomy and subsequent reconstruction.

Antognazza [6] believes that many people who desire or “believe to desire” aesthetic treatments suffer from neurosis and a narcissistic personality disorder. Although they may perform successfully, socially, and professionally, they have a precarious sense of identity. This is the result of fragile personality organization, which is based on a psychological system called “beliefs of absolute truths” that cannot be discussed. These are human beings who sustain themselves, despite their low self-esteem, via self-sufficient behaviors and perceptions of personal importance and grandness. Inside, however, they are hypersensitive to frustration and failure.

Faced with this scenario, it is evident that if an outcome does not provide a change in personal relationships, considering the importance of a woman’s breasts as a symbol of her femininity, dissatisfaction will appear. In fact, the technical skills of the doctor are seen as less important than issues like the poor communication and patient-related behaviors.

Professional Responsibility

The following pages provide an overview of the legal side of the practice of medicine. It is a broad overview, meant only to give practitioners a general idea of the legal implications and consequences, because each of the 50 states in the USA is a sovereign entity unto itself and enacts its own statutes and case law. It is advisable, therefore, for medical practitioners to consult competent legal counsel in the jurisdiction in which they practice medicine. It is unreasonable for the medical practitioner to rely solely on the following legal concepts: No warranties, expressed or implied, are given to the reader.