Scheduling and Following Through with a Cosmetic Surgical Procedure

Jonathan M. Sykes

“Good judgment comes from experience; experience comes from bad judgment.”

The goal of the facial plastic surgeon is to satisfy the cosmetic surgery patient. To achieve this goal, the surgeon must exhibit good judgment in many aspects of medical and surgical practice. Good judgment on the part of the facial plastic surgeon requires focused observation and keen awareness.

A successful outcome in plastic surgery begins with the patient’s first contact with the office, continues through the consultation and surgical procedure, and proceeds throughout all postoperative follow-up visits. Most postgraduate plastic surgery education emphasizes surgical technique and how-to-do surgical procedures; however, a successful plastic surgery practice is based on the surgeon’s ability not only to complete the operation but also to select patients and attend to their needs and wants. This chapter provides an in-depth look at the process of interacting with the cosmetic surgery patient: the initial consultation, patient photography and imaging, scheduling of surgery, fee agreement, and informed consent. Additionally, postoperative issues such as the follow-up visits, aesthetician services, such as manual lymphatic drainage (MLD) and cosmetics, and dealing with patient dissatisfaction are addressed. It is clear that satisfaction after plastic surgery procedures requires meticulous attention to each of these details. They are as important as the surgical procedure itself.

♦ The Initial Patient Contact

The evaluation process of the cosmetic surgery patient should begin with the initial patient contact. The first contact with the prospective patient is usually a telephone call. The behavior exhibited during the initial phone call is often important and can set the tone for the physician-patient relationship that follows. Every piece of information obtained during the initial (and all subsequent) phone conversations should be used in evaluating whether the patient is an appropriate candidate for surgery. If any abnormal or inappropriate comments are made during any phone conversations with staff, these should be carefully documented in the chart.

The observations of nursing and office staff should be used in evaluating the cosmetic surgery patient. Office staff members often witness patient behavior that is different than the behavior used in front of the physician. The patient who is overly demanding or requires special treatment often will exhibit these traits to office staff. Although patients are often on their best behavior with the surgeon, they may treat the staff with a lack of respect. For these reasons, the opinions and observations of office staff are invaluable, often providing information that is not obtainable by the surgeon.

♦ The Consultation

The initial consultation between the facial plastic surgeon and patient is a complex interaction that involves two-way diagnosis and decision making. The surgeon is evaluating the medical history of the patient and the 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. The patient simultaneously is evaluating the surgeon and deciding whether to be operated on by the surgeon.

Most patients seeking a plastic surgery consultation have already thought about the decision-making process regarding surgery. As opposed to noncosmetic surgery patients who often hope that surgeons will recommend that the patient not have 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, “Will the surgeon be able to improve the function and appearance of my face?” The less-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 has an important evaluation of the patient’s psychological profile during the consultation.1 This begins with the surgeon trying to understand the patient’s position and perspective and, importantly, his or her motivation for having surgery.² If the surgeon feels that the patient has a poor self-image and is generally an unhappy person, the patient’s motivation for surgery may be to create personal happiness. If the surgical results are disappointing to these patients, the resulting dissatisfaction is accentuated. Furthermore, patients with poor self-image are more likely to have surgery not meet their expectations. The failure to meet a patient’s expectations usually results from the patient initially having an unhealthy motivation for surgery. All of these factors mandate that the surgeon be aware of the patient’s psychological profile and to communicate any potential issues with the patient preoperatively.

♦ Selecting Patients

The first step to obtaining a successful outcome in facial plastic surgery is to carefully select the patient. This requires the surgeon to delve beyond the surface and to determine the patient’s inner strength and ability to deal with the postoperative healing process.³ Surgeons are taught how and when to operate, but the skill of when not to operate requires experience and good judgment. At the end of a surgeon’s career, he or she will rarely be disappointed at not having operated on a particular patient; however, operating on the wrong patient (with a poor psychological profile) often creates anger and frustration on the part of both the patient and the 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 18.1 lists patients who may be predisposed to unhappiness or dissatisfaction.

**Table 18.1** Patients Who May Be Predisposed to Dissatisfaction with Plastic Surgery
Overly demanding Unrealistic expectations Poor self-image Perfectionist Body dysmorphic disorder Patient critical of past surgery or medical care Patients with prior depression or psychiatric disorders

♦ Photography and Video Imaging

The use of photography and imaging by the facial plastic surgeon is both helpful and essential. The patient often requests photographic documentation of the surgeon’s competence (i.e., other preoperative and postoperative results) and imaging of their potential postoperative appearance. The surgeon needs photographic documentation as an ongoing learning tool and as a permanent medical record.

Preoperative and postoperative photography allows the surgeon to use surgical planning and to retrospectively look at outcomes of a particular technique. Photographs need to be consistent in lighting, positioning, and background. Archiving of photographs requires easy image retrieval and a system that allows cross-referencing by the surgeon. Accessibility to photographs needs to maintain patient confidentiality and comply with HIPPA regulations.

The five standard views obtained for facial rejuvenation surgery are frontal, lateral (two; left and right), and oblique (two; left and right) (Fig. 18.1). These photographs should be taken approximately 3 ft (1 m) away from the patient and should be 3:2 (vertical:horizontal). If periorbital surgery is to be performed, close-up photographs of the periorbital region should be obtained from approximately 2 ft away. These periorbital photographs should also be taken in the above-mentioned five positions. Additionally, a periorbital frontal photograph should be obtained with the patient in upward gaze (Fig. 18.2).

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