2 The goals and expectations of patients seeking plastic surgery are complex. For most patients, the overt desire is to change their physical appearance or function. However, patients have unspoken desires, which may include improving their self-esteem and overall quality of life. Although unstated, these desires to improve overall quality of life clearly affect an individual patient’s eventual satisfaction with his or her surgical outcome. The goal of the facial plastic surgeon is to achieve the best possible aesthetic and functional surgical outcome. However, improved function and aesthetic appearance are clearly matters of the individual’s perception. An individual patient’s perception of their surgery is a product of many factors that include not only the physical result but also the less objective characteristics of self-esteem and ego strength. This chapter focuses on diagnosis and treatment of the psychological aspects of the plastic surgery patient. This includes preoperative identification of the well-adjusted patient, who is likely to appreciate the benefits of well-performed surgery. The preoperative consultation should also identify potentially problematic patients. This chapter outlines a systematic approach to evaluate patients who are likely to be dissatisfied with plastic surgery and provides an algorithm for dealing with these patients. A detailed outline of how to communicate with all patients is included. Although the plastic surgeon receives minimal training in dealing with the psychological concerns of the plastic surgery patient, attention to this subject is mandatory for a successful plastic surgery practice. The initial consultation between the facial plastic surgeon and a prospective patient is a complex interaction that involves two-way diagnosis and decision making. While evaluating the medical history and physical suitability of the patient, the surgeon is also beginning a process of deciding whether or not the patient is a good psychological candidate for surgery. Simultaneously, the patient is evaluating the surgeon and deciding whether to be operated on by the surgeon. Most patients seeking a plastic surgery consultation have already considered the process of making a decision about surgery. Unlike non-cosmetic surgery patients, who often hope that surgeons will recommend not having surgery, plastic surgery patients desire change and usually request surgery. For this reason, careful communication during the consultation is essential in establishing a healthy and open surgeon-patient relationship. It is important that the surgeon identify characteristics that may predispose the patient toward postoperative dissatisfaction with the surgical result. The personality characteristics of both the patient and the surgeon are noticeable during the initial consultation. The overt goals of the patient are to evaluate the competence and expertise of the surgeon; that is, to answer the question “Will the surgeon be able to improve the function and appearance of my face?” The less frequently stated goals of whether or not the surgeon can care for and comfort the patient during the healing process are at least as important as surgical competence is to the patient. Thus, the decision to choose a given surgeon is a complex one based on reputation, perceived competence, empathy, and comfort during the consultation. The surgeon also must make an important evaluation of the patient’s psychological profile during the consultation. This begins with the surgeon trying to understand the patient’s position, perspective, and (most importantly) motivation for having surgery. If the surgeon feels that the patient has a poor self-image and is generally unhappy, the motivation for surgery may be to create personal happiness. If such patients are disappointed with the surgical results, their resulting dissatisfaction is accentuated. Furthermore, if patients have poor self-image, it is more likely that surgery will not meet their expectations. The failure to meet patient’s expectation usually results from a patient’s initial unhealthy motivation for having surgery. All of these factors mandate that the surgeon be aware of the patient’s psychological profile and communicate any potential issues with the patient preoperatively. The first step to obtaining a successful outcome in facial plastic surgery is to select the patient carefully. This requires the surgeon to delve beneath the surface and to determine the patient’s inner strength and ability to deal with the postoperative healing process. Surgeons are taught how and when to operate, but the skill of knowing when not to operate requires experience and good judgment. At the end of their careers, surgeons will rarely be disappointed that they did not operate on a particular patient; however, operating on the wrong patient (one with a poor psychological profile) often creates anger and frustration for both the patient and surgeon. To exclude or discourage certain facial plastic surgery patients from having surgery, the surgeon must be aware of patient profiles that are problematic. Table 2.1 lists the traits of patients who are predisposed to unhappiness or dissatisfaction. Patients who exhibit the need for special treatment from either the doctor or staff are difficult to please and will tend to be dissatisfied with their surgical results. These patients will often request special treatment, including special timing for their appointments. They will often seem annoyed by or irritated with the manner in which they are treated. Physicians should listen carefully to staff warnings regarding these patients, as demanding patients will often mask these characteristics from their physicians. Patients who need to control every detail relating to surgery are also potential problems. These patients ask many detail-oriented questions and often bring in many photographs depicting their desired results. Perfectionist patients often do not understand the limitations of surgery. In addition, these patients will often be preoccupied with minimal aesthetic problems or deformities. These patients require a significant time commitment from the surgeon to explain surgical limitations and to set appropriate and realistic expectations. If appropriate surgical expectations are set and limitations of surgery are outlined in advance, perfectionist patients can be very pleased with postoperative results. Table 2.1 Behaviors Associated with Body Dysmorphic Disorder2
Management of the Dissatisfied Patient
Preoperative Considerations
The Consultation
Selecting Patients
The Demanding Patient
The Perfectionist Patient
• Frequent glancing in reflective surfaces • Avoidance of mirrors • Skin picking • Repeatedly measuring or palpating the defect • Repeated requests for reassurance about the defect • Elaborate grooming rituals • Camouflaging some aspect of the patient’s appearance with a hand, a hat, or makeup • Avoiding social situations where others might see the defect • Social anxiety • Depressed mood and suicidal ideation |
Patients Critical of Other Surgeons
A patient who is dissatisfied with prior aesthetic surgery and is vocally critical of past medical care is a dangerous patient to treat. The facial plastic surgeon should listen carefully to how the criticism is spoken. If a patient explains a prior surgery with an underlying tone of anger, this patient should be avoided. If the surgeon operates on the patient before the anger issues are dealt with, the anger will likely resurface during the postoperative period after the revision surgery.
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