Psychological Aspects of Plastic Surgery: A Surgeon’s Observations and Reflections

Robert M. Goldwyn MD

Like any physician, the plastic surgeon can greatly benefit from developing a reasonable set of psychological skills that he or she can use in providing the highest level of care. This is a necessity not a luxury, because it can mean the difference between a successful or unsuccessful outcome, for both the patient and the surgeon. For example, the plastic surgeon performing a cosmetic procedure must realize that a technically well-performed operation does not guarantee a satisfied patient (1). It is quite often the case that understanding the patient’s motivations and personality can be as crucial to the ultimate outcome as undertaking the actual surgical procedure. Similarly, surgeons should be aware of their own motivations and attitudes toward their practice. It is important that each plastic surgeon have a willingness and capacity to engage in introspection.

This chapter provides a plastic surgeon’s view of the psychological aspects of plastic surgery. It begins with a general discussion of basic preoperative considerations. Several specific patient types associated with an increased likelihood of a poor postoperative outcome are highlighted. Postoperative considerations, particularly as they relate to issues of patient satisfaction, are also reviewed. This chapter concludes by addressing the question: “Can plastic surgeons enhance their psychological skills?”

PREOPERATIVE CONSIDERATIONS

From the plastic surgeon’s point of view, the major objective of the initial consultation is likely the proper selection of the patient. The patient’s medical history and current status determine whether the patient is medically appropriate for a given procedure. Cosmetic surgery is almost always elective, and patients are almost always in good health. The patient, however, is willing to risk this good health (at least to a limited extent) in order to experience improvements in physical appearance, and perhaps more importantly, self-esteem, body image, and quality of life. In this context, the plastic surgeon is in the somewhat odd position of making a healthy patient “ill” in order to help him or her feel better about himself or herself.

Perhaps as a result of this, the initial consultation in plastic surgery is more important than any other visit. The consultation with a cosmetic surgeon is different from other surgical consultations in at least one respect. In cosmetic surgery, the patient is, more often than not, hoping that the surgeon will recommend surgery. By contrast, in the case of neurosurgery or orthopedics, for example, the patient is likely hoping that the surgeon will not recommend surgery. In some respects, this difference places a greater emphasis on the nature of the surgeon-patient interpersonal relationship than is likely found in other surgical specialties.

The initial consultation brings together a patient and surgeon who have probably never known each other. Each brings with them an established personality with behavior patterns evolved from innumerable responses to countless previous social interactions and life events stimuli (2). In theory, the patient and the surgeon could interact in infinite ways in this initial meeting. In reality, they do not. Rather, both likely behave in a manner more or less consistent with typical sociocultural roles. What happens is remarkably circumscribed. The patient is there to decide whether or not to receive care from the surgeon or to convince the surgeon to comply with his or her desire to have surgery. In turn, the surgeon is making a decision concerning whether or not to accept that person as a patient. This evaluative process puts the personality characteristics of both individuals on display.

The patient can recognize arrogance, hostility, and other negative personality traits even when the surgeon believes that these traits are well hidden (or is unaware of them). Similarly, the patient who has been kept waiting an inordinately long time will recognize and appreciate a sincere apology and not one that is perfunctory. As much as possible, it is useful for the surgeon to imagine himself or herself in the role of the patient. By doing so, the surgeon will find it easier to understand the patient’s perspective and, perhaps, the patient’s motivations and emotions. This awareness will likely have a positive impact on rapport.

By imagining themselves in the position of the patient, surgeons may have a better understanding of the guilt and embarrassment experienced by some cosmetic surgery patients who may be at least mildly ashamed about seeking surgery to improve appearance. Cosmetic surgery involves the elusive objective of happiness, which is an implied outcome of a successful postoperative result. Again, this is in contrast to other areas of medicine, where the efficacy of therapy is usually measured in terms of the reduction or elimination of symptoms or improved function. The prolonged recoveries often observed in other surgical specialties are seen with far less frequency in cosmetic surgery. Patients who experience complications that result in an unexpectedly long recovery are often disappointed and angry. As discussed later in this chapter and also in Chapter 19, the quality of the surgeon-patient relationship becomes critically important in these situations.

POTENTIALLY PROBLEMATIC PATIENTS FROM A PSYCHOLOGICAL PERSPECTIVE

Individuals with a variety of personality types are believed to be potentially problematic patients in a plastic surgery practice (2, 3, 4, 5). (Several of these patient types are also discussed in the context of patient selection from a legal perspective in Chapter 19.) Persons with these characteristics require careful evaluation by the surgeon, and often by a qualified mental health professional, before being accepted as a surgical patient. Although not formally studied, mental health professionals would likely diagnose these individuals with personality or other disorders. Several chapters throughout this book discuss the formal psychiatric diagnoses likely to be seen within select groups of plastic surgery patients.

The VIP Patient

The VIP patient may be a local or national celebrity, professionally successful, or simply an individual who believes that he or she warrants special treatment from the surgeon and staff. These patients’ strong sense of entitlement leads them to expect special treatment and not to be held to the same rules as others. A VIP patient’s renown, wealth, or power does not change anatomy or physiology and certainly does not eliminate the hazards of undergoing any procedure.

The danger with this type of individual is that surgical judgment may be in deference to fame or self-importance. Without realizing it, and without the patient demanding it, the surgeon may make medical decisions for the VIP patient that he or she would not make for others. Departure from the surgeon’s routine office practice, standards of care, or personal comfort zone may increase the likelihood of an undesirable result (3). As highlighted in Chapter 16, members of the office or nursing staff may be the first to recognize these patients. They may be on their best behavior with the surgeon, but treat the staff with a lack of respect or decency. Surgeons should encourage staff to alert them about such behavior.

The VIP patient often has difficulty dealing with routine office procedures. Some refuse to accept the next available appointment and will try to bypass the secretary to be seen earlier. Others may herald their initial visit with a letter or phone call that is not simply providing information but is also pleading their case for surgery and appealing to the surgeon’s ego (as discussed below). Generally such letters contain an obsessively described saga of repeated dissatisfaction following multiple treatments of a condition that may be objectively less major than the patient believes. In these cases, as well as others where there is concern about a patient’s previous surgical treatment history, previous medical records should be obtained.

During the consultation, some patients may become overly friendly with the surgeon. Some may address a doctor on a first name basis without asking. Occasionally, surgeons may find themselves in consultation with patients who have made themselves overly comfortable in the office or consultation room. The patient may look through papers or remove books from the shelves. In my experience, this patient is less curious than aggressive and wishes to assume control of his or her care by establishing an immediate intimacy. This behavior may reflect some underlying anxiety about dependency and perhaps the patient is trying to allay uneasiness by dominating the situation.

When these VIP patient behaviors force the surgeon to practice outside of a typical comfort zone, it may be useful to call to the patient’s attention that they seem to be having a difficult time being a patient. The surgeon may even consider disclosing an understanding of the problem, because he or she, as a physician, also has difficulty being a patient. In fact, sometimes this kind of patient is a physician.

The Patient Who Appeals to the Surgeon’s Ego

Some patients understand that few surgeons, like most people, can resist flattery. This patient may plump the surgeon’s ego with praise, saying, “I heard you are the best in town/in the country/in the world.” In reality, the patient usually has no valid frame of reference for this opinion and may be responding to a flattering newspaper story or word of mouth from friends. Such adulation should not persuade the surgeon to perform an operation that will never satisfy the patient.

Some patients may appeal to the surgeon’s ego through flirtation. In these instances, the surgeon must immediately restructure the interaction to stop this inappropriate behavior. This often can be done by speaking to the patient in a serious, matter-of-fact tone and avoiding intimate conversation and playful banter. The surgeon should like-wise monitor the use of unnecessary personal touch as well as more flippant (“Honey, you will look beautiful”) or sexual language (“You will look really hot after surgery”). When interacting with patients of the opposite sex, particularly when they are undressed, it is advisable to have a nurse or staff member of the patient’s sex in the room.

The out-of-town patient, who comes from a great distance, may directly or indirectly appeal to the surgeon’s ego. As a surgeon’s reputation grows, so will the radius of referrals. Surgeons may feel a glow when a patient comes from afar to get their opinion or receive their care. However, this situation poses several potential problems. The first is that both the patient and the surgeon may feel pressured to decide immediately on a course of treatment. Frequently, a patient may have been tentatively
scheduled for an operation even before being seen, a situation that is not optimal but occasionally unavoidable. It is much harder to refuse to operate on the patient under those circumstances. Another problem with the patient from faraway is that communication with the referring physician is not always easy. Most importantly, however, is that should something go wrong, these patients are not near their usual support of family and friends. Sometimes a postoperative patient returning home may have difficulty obtaining surgical follow-up should it be necessary. The patient from afar should certainly be given an opportunity to be a patient, but the surgeon should be aware that someone who experiences a complication or is dissatisfied with the result can best be managed if living minutes, not hours, away.

The Perfectionistic Patient

The perfectionistic patient can present for surgery in many forms. The “minimal deformity” patient reports an excessive degree of preoccupation with a comparatively modest deviation from a “normal” appearance (6). The “insatiable” patient (also described as the “Surgiholic Patient” in Chapter 19) may return to the same or often different surgeons with complaints that a given feature is “just not right” despite a series of revision procedures (7). As discussed in Chapters 14 and 16, descriptions of these patients are consistent with present-day descriptions of persons with body dysmorphic disorder.

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