Section I Complications Prevention Essentials

Eric T. Carniol


The preoperative stage of a surgeon-patient relationship is important in order to assess physical and psychological candidacy for a procedure and establish realistic expectations. Surgeons must be prepared to deny treatments to patients who are not candidates as well as build trust with patients with whom they would like to continue with treatment. The surgeon-operated patient relationship is permanent, and both parties must understand and willingly enter into this relationship.

1 General Approach: The Consultation—Patient Evaluation

1.1 Introduction

The goal of minimally invasive facial rejuvenation or aesthetic/cosmetic procedures is to enrich a patient’s life by improving a perceived flaw in function or appearance. The initial consultation is important in avoiding and minimizing complications from procedures. This first meeting between the physician and new patient is an important opportunity to establish a strong enduring relationship. For the physician, it is imperative to identify the patient’s goals and aspirations and to determine the appropriate potential procedure or procedures. For the patient, it is imperative to express those goals and establish realistic expectations. Patient selection is of paramount importance, and the issues related to patient selection can be challenging. There are four main components. First, how likely is the identified procedure(s) going to yield the change that the patient is seeking? The answer to this and other related issues will be discussed in the chapters that follow. The second component is patient selection. The third component is procedure execution, and the final component is any care, if appropriate, that is required after the procedure.

Patients today can do extensive research on both a desired procedure and their potential physician. It is important for the physician to recognize that the patient will probably present with a fair amount of information about the procedure being requested. This comes with additional challenges, as some of the information may not be accurate or may not be applicable to the patient or their concerns. The physician should be prepared to discuss the risks, benefits, and alternatives to the procedure in addition to respectfully addressing any misinformation that the patient may have acquired from their own research. It is important to demonstrate expertise when addressing any misinformation.

Many patients seek multiple opinions and consultations prior to deciding upon a physician and procedure; therefore, during this time, it is imperative for the physician to ensure that she/he engages the patient in a physician–patient relationship. As the aphorism goes, “The preoperative period is finite. The postoperative period is infinite.”

Once goals and expectations are identified, discussed, and agreed upon, the physician should pursue a structured conversation regarding the remainder of the treatment experience. A well-described and adapted structured discussion is the R-DOS model, adapted from Daniel Sullivan, founder of “The Strategic Coach.” 1

The first question (The R-Factor) is “If we were to meet here in one year and look back over the year, what would have happened, both personally and professionally, for you to be satisfied with your progress in life?” While the answer usually has little to do with the requested procedure or displeasing bodily feature, the answer will reflect whether the physician and the patient will have an ongoing relationship that will last at least one year. The answer, as with all answers, is important to note as precisely as possible. This allows the physician to utilize the patient’s own language, a process known as reflective listening. 2 If a potential patient has difficulty answering this question, it is worth asking if they anticipate that the procedure being discussed has the potential to change their future. This may be the situation for a patient with a significant deformity or problem. However, for a more frequent, relatively straightforward cosmetic procedure, it is unlikely that the procedure will change their future. Patients who anticipate that a relatively small cosmetic procedure will change their lives expect too much from the procedure and may become unhappy with the outcome when their life does not change. Therefore, these patients should be avoided.

The second question relates to the patient’s perceived risks of the procedure. “When thinking about [the procedure/body part], what specific questions or concerns do you have?” Writing down these questions also imparts to the patient that you are listening and that you are attentive to their concerns. These questions also give the physician an insight into the emotionality that the procedure or the disliked feature plays on the psyche of the patient. The concerns or questionsare the only negative part of the interaction. The physician should go over every question with the patient for completeness. Once addressed, the discussion can be (permanently) shifted to the positive.

Opportunities: Once the concerns have been addressed, attention in the conversation can be moved to the future. “Pretend that it is one year in the future and that you have had the successful procedure, what will that do for you?” Although this question can seem similar to the R-Factor, it instead shifts the patient’s focus to the future, once the procedure and the recovery are finished.

Strengths: Many times, patients have already addressed their personal strengths in the consultation. However, this is the time to address strengths specifically and continue to build on them. “What are your strengths and how will this procedure build on them?”

The R-DOS conversation allows the physician to gain key insight into the patient. By assessing these, the physician can decide whether a patient is a candidate for surgery. There are some patients who are unable to provide quality responses to these questions, or are so apprehensive about these questions that they will refuse.

If the patient is unable to imagine their future and their place in it, they may also be unable to imagine their postprocedure recovery and may have increased difficulty adjusting to their postoperative result. Some prospective patients may also describe secondary gains from surgery such as change in social stature, renewal of love or attention from a significant other, or maintenance/attainment of a job. These responses help the physician identify a potentially unhappy patient. The physician may also determine that the prospective patient is not someone with whom they would like to engage in a permanent physician-operated patient relationship.

This conversation can help a patient frame their surgery as not just an outcome or a good that is purchased, and instead as an experience that they will use to continue to improve their life. After going through the R-DOS conversation, patients have increased engagement and higher rates of conversion to and satisfaction from their procedure.

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Mar 28, 2021 | Posted by in Dermatology | Comments Off on Section I Complications Prevention Essentials
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