In discourses on patient selection in cosmetic and laser surgery, there is an emphasis on ensuring that the patient has so-called “reasonable expectations.” The difficulty lies in defining this phrase and in ascertaining whether a particular patient meets the test. Among the useful cues are facial expressions and the patient’s responses to the physician’s discourse.1 A patient who nods in response and asks appropriate questions in a modulated voice of moderate volume is reassuring for the physician. The implication is that the patient is a partner in the discussion and is both understanding what the physician is saying and agreeing with the physician’s plan. An excessively emotional, or alternatively stone-face and hostile, patient is cause for concern.

Much has also been written about the unsuitability for cosmetic procedures of patients with body dysmorphic disorder. The full-blown disorder is probably uncommon among patients seeking laser treatment. But less extreme variants are seen often. In brief, the problem is that some patients perceive their own bodies in an unrealistic manner.2 Minor flaws are seen as major disfigurement, and some normal features are viewed as problems needing correction. Such patients are chronically dissatisfied with their appearance, and there may be no limit to the number of complaints they have. Correcting a given complaint with a perfectly executed laser procedure will be of no value: either the patient will immediately generate another complaint, or they will deny that the first was adequately treated despite objective evidence to the contrary.3

Identifying the patient with body dysmorphic disorder or a lesser subtype is not always simple. Patients may be expert at concealing their pathology. They may appear eminently reasonable. Evidence in support of a diagnosis of body dysmorphic disorder is a large number of prior surgeries or procedures to address the same problem.4 These may be invasive surgeries like rhinoplasty or rytidectomy that are seldom repeated multiple times, and they may have been performed by a number of different physicians.

A surgeon who is convinced that a patient has body dysmorphic disorder should refer the patient for appropriate counseling with a mental health professional. If there is some doubt about the diagnosis, it may be appropriate to consult with or refer the patient to another cosmetic surgeon for a second opinion. If the diagnosis is far from certain and the physician thinks the patient is anxious but not mentally ill, it may still be preferable to avoid any major procedures until the patient has undergone some minor nonablative procedures and evinced a satisfactory post-treatment course.

Patients with depression and anxiety disorders, schizophrenia, and other psychiatric disorders may present for laser surgery. Importantly, these conditions are not absolute contraindications for treatment. Patients who understand their illness, are appropriately medicated, and are under the care of a physician who is both managing their mental illness and supportive of their desire for laser surgery may in fact be appropriate laser patients. Needless to say, patients with mental illness who lack insight and whose underlying disease is not managed are not suitable candidates for laser procedures.

One problem in the post-operative period is picking and self-mutilation.5 Picking behaviors are often exacerbated by the appearance of what is perceived as “damaged” skin, such as the re-epithelializing skin after ablative resurfacing. Since picking can lead to prolonged healing and scarring, picking should be treated before ablative or partially ablative laser treatments are commenced.

Not uncommonly, laser physicians see patients who are unhappy with doctors who have treated them previously. On initial presentation, such patients may convey delight at having finally found the perfect, best qualified physician for their needs. They may relate the horrors of prior experiences with different physicians, who were in their estimation incompetent and dangerous quacks. These patients may be effusive and smiling, and convey their relief at finally being under the care of a master and magician, the physician in question.

While this level of approbation can be intoxicating for the physician toward whom it is directed, caution should be exercised in treating patients who present thus. Often, dissatisfaction with prior physicians is founded not on the incompetence of these professionals but rather on unrealistic patient expectations that could not have been, and hence were not, met.6 Patients who hated their other doctors, may soon come to hate their current doctor. In such patients, there is a pervasive tendency to view physicians as either all good, or all bad. Oversimplification of this type is incompatible with the more shades-of-grey medical model, in which good care often results in partial resolution of ill-defined problems.

In working with a patient of this type, it may be wise for the physician to communicate forcefully early in the consultation that he or she is quite certainly unable to help the patient in the manner they seek. Additional referrals may be provided to other physicians who may or may not be able to assist the patient. Disappointing the patient early in the process may, for the physician, be preferable to managing an unhappy patient after treatment.

Some patients have very high standards. They may ask to have removed minute lentigines that are difficult to see. Or they may request a further scar revision for an accident-induced scar that was previously expertly revised and is now a faint flat line.

In considering the needs of such patients, it is important to maintain a realistic appraisal of what is possible. One approach is for the physician to communicate that he or she definitely understands the patient’s concern, but is unsure that he or she has the means to resolve it. The physician may wish to share that given the subtlety of the defect, it is difficult to say whether it would be improved, unchanged, or even exacerbated after a laser procedure. Since no physician is omniscient, it is reasonable to concede that some other laser surgeon may offer a superior treatment strategy associated with a greater likelihood of success; it may thus be appropriate for the physician to suggest a second opinion be obtained from another laser expert in the area. If the initial physician chooses to treat the minor defect perceived by the patient as a major one, the physician should be prepared for a dissatisfied patient after treatment. To avoid this, the physician should be clear about the weak prospects for improvement, and the likely need for many treatments; a comprehensive oral and written consent may be obtained.

Some energy procedures, such as nonablative skin tightening, do not provide all patients with similar benefits. Perhaps a fourth of patients obtain excellent results, another half have modest improvement, and a quarter may have no discernible change from baseline. If there is a reasonable likelihood that a laser procedure will be unsuccessful for a particular patient, it is important to communicate this before the procedure is performed. It is more credible for the physician to predict lack of response than to justify it after it has happened. Prediction implies superior knowledge and honesty; justification after the fact suggests lack of competence and the possibility that a mistake is being rationalized. Of course, any laser procedure, and any medical procedure in general, can be ineffective in a specific case without any physician fault. But when such an outcome is probable, it behooves the physician to clearly communicate this in a pre-emptive manner. In general, it is better to lose a patient than to regret having performed a procedure on a now unhappy patient, who feels mislead and whose needs have not been met.