The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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The Unfavorable Result in Plastic Surgery
Avoidance and Treatment
Fourth Edition
EDITORS:
Mimis N. Cohen, MD, FACS, FAAP
Professor and Chief
Division of Plastic, Reconstructive, and Cosmetic Surgery
Director, Craniofacial Center
University of Illinois
Chicago, Illinois
Associate Editors:
David J. Birnbach, MD, MPH
Professor and Vice Provost
University of Miami Miller School of Medicine
Director
Jackson Memorial Hospital Center for Patient Safety
Miami, Florida
Joshua Fosnot, MD
Assistant Professor
Department of Surgery
Division of Plastic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Lawrence J. Gottlieb, MD, FACS
Professor of Surgery
Director of Burn & Complex Wound Center
Section of Plastic and Reconstructive Surgery
The University of Chicago Medicine & Biological Sciences
Chicago, Illinois
David T. Netscher, MD
Professor
Department of Orthopedic Surgery and Division of
  Plastic Surgery
Baylor College of Medicine
Adjunct Professor of Clinical Surgery
Houston Methodist Hospital/Weill Cornell Medical College
Houston, Texas
Zubin Jal Panthaki, B. Eng. (Hons, Elec.), MD, CM, FACS
Professor of Clinical Surgery
Department of Plastic Surgery
Professor of Orthopaedics
Department of Surgery
University of Miami Miller School of Medicine
Miami, Florida
Seth R. Thaller, MD, DMD, FACS
Professor and Chief, Program Director
Division of Plastic, Aesthetic, and Reconstructive Surgery
University of Miami Miller School of Medicine
Miami, Florida
Pravin K. Patel, MD, FACS
Professor of Surgery
Chief of Pediatric Plastic and Craniofacial Surgery
The Craniofacial Center
Division of Plastic, Reconstructive, and Cosmetic Surgery
University of Illinois
Chicago, Illinois
Linda G. Phillips, MD
Truman G. Blocker, Jr., MD, Distinguished Professor
  and Chief
Division of Plastic Surgery
Department of Surgery
University of Texas Medical Branch
Galveston, Texas
Joseph M. Serletti, MD
The Henry Royster-William Maul Measey Professor of
  Surgery and Chief
Division of Plastic Surgery
University of Pennsylvania Health System
Philadelphia, Pennsylvania
James M. Stuzin, MD
Clinical Professor of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
Peter J. Taub, MD, FACS, FAAP
Professor of Surgery: Pediatrics, Dentistry,
  and Neurosurgery
Professor of Medical Education
Division of Plastic and Reconstructive Surgery
Icahn School of Medicine at Mount Sinai
Chief, Pediatric Plastic Surgery
Director, Cleft and Craniofacial Center,
Kravis Children’s Hospital
New York, New York
3267 illustrations
Thieme
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    Sarah Vanderbilt
President: Brian D. Scanlan
Library of Congress Cataloging-in-Publication Data
Names: Cohen, Mimis, editor. | Thaller, Seth, editor.
Title: Unfavorable results in plastic surgery : avoidance
    and treatment /
    Mimis Cohen MD, FACS, FAAP, Professor and Chief,
    Division of Plastic,
    Reconstructive and Cosmetic Surgery, Director
        Craniofacial Center,
    University of Illinois, Chicago, IL, Seth Thaller, MD,
        Professor and Chief
    University of Miami Division of Plastic Surgery, Miami, FL.
Description: 4th [edition]. | New York : Thieme, [2018] |
    Includes bibliographical references and index.
Identifiers: LCCN 2017030614 (print) | LCCN 2017032596
    (ebook) | ISBN
    9781626237636 (e book) | ISBN 9781626236745
        (print : alk. paper) | ISBN
    9781626237636 (ebook)
Subjects: LCSH: Surgery, Plastic--Complications.
Classification: LCC RD118.7 (ebook) | LCC RD118.7 .U54
    2018 (print) | DDC 617.9/52--dc23
LC record available at
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Dedicated to the memory of Robert M. Goldwyn (1930–2010), world-renowned plastic surgeon,
outstanding teacher, respected mentor, and a great friend.
v

This book is dedicated to my wonderful wife Andrea, who has been standing by my side and supporting my academic
career for over 35 years, and to my daughter Saranna, the light of my life.
Mimis N. Cohen, MD, FACS, FAAP
To my wife Pat who has always been there for me and will continue to be for the foreseeable future. She will always guide
our lives. My parents Jack and Phyllis, who have left an indelible footprint on my journey. My children, Steven Cody and
Alexandra Lee, who have added so much light and joy to our days.
Seth R. Thaller, MD, DMD, FACS
vi

Contents
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xi
Preface to the First Edition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface to the Second Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface to the Third Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
Video Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix
Volume One
Section I Introduction
1
Why We Fail. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Robert M. Goldwyn
2
The Dissatisfied Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Robert M. Goldwyn
3
Psychological Aspects of Cosmetic

Surgery and Minimally Invasive Treatments. . . . . . . 14

David B. Sarwer and Heather M. Polonsky
Section II Legal and Safety Issues
David J. Birnbach, Associate Editor
4
Ethics and Plastic Surgery Practice. . . . . . . . . . . . . . . . 25

Kenneth W. Goodman and David J. Birnbach
5
Informed Consent, Record Keeping, and

Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Neal R. Reisman
6
Bringing High Reliability to the Operating Room. . . 36

John T. Paige
7
The Legal Implications of Unfavorable Results. . . . . 49

Christopher L. Nuland
8
Medical Malpractice and Plastic Surgery. . . . . . . . . . 54

David R. “Chip” Barry, Jr.
9
Disruptive Behavior: The Imperative for

Awareness and Action. . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Sheri A. Keitz and David J. Birnbach
10
Safety in the Outpatient Setting. . . . . . . . . . . . . . . . . . 65

Geoffrey R. Keyes
11
Disclosure of Adverse Events: A Principled

Approach to Doing the Right Thing . . . . . . . . . . . . . . . 73

David J. Birnbach and Timothy B. McDonald
Section III General Problems
Linda G. Phillips, Associate Editor
12
Scars and Scar Revisions. . . . . . . . . . . . . . . . . . . . . . . . . 81

Warren Garner

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Tulsi Roy and Raphael C. Lee
13
Surgical Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Jillian M. McLaughlin, Ali Shirafkan, and

Linda G. Phillips

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

William C. Lineaweaver
14
Wound Management. . . . . . . . . . . . . . . . . . . . . . . . . . 112

Aditya Sood, Vasanth S. Kotamarti, and

Mark S. Granick

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Dennis P. Orgill
15
Microsurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Abigail M. Cochran and Michael W. Neumeister

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Milomir Ninkovic
vii

viii
Section IV Aesthetic Surgery
James M. Stuzin, Associate Editor
16
Dermal Fillers and Neurotoxins. . . . . . . . . . . . . . . . . 145

David Kenneth Funt

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Karol A. Gutowski
17
Laser Facial Resurfacing. . . . . . . . . . . . . . . . . . . . . . . . 176

Mark S. Nestor, Mitchell Manway, and

Paige Paparone

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Lawrence S. Bass and Jason N. Pozner
18
Chemical Peels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

Gustavo A. Rubio and Thomas J. Baker

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

James E. Zins and Ahmed M. Hashem
19
Fat Grafting for Facial Rejuvenation. . . . . . . . . . . . . 205

Sydney R. Coleman and Riccardo F. Mazzola

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Donald S. Mowlds and Val Lambros
20
The Forehead Lift: Open and Endoscopic. . . . . . . . 223

Cristiano Boneti and Luis O. Vasconez

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Foad Nahai
21
Face and Neck Rejuvenation. . . . . . . . . . . . . . . . . . . . 240

James M. Stuzin

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

Timothy J. Marten
22
Blepharoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Kevin H. Small and Henry M. Spinelli

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Michael P. Ogilvie and Julius W. Few Jr.
23
Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Enrico Robotti

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322

Mark B. Constantian
24
Secondary Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . 332

Ali Totonchi and Bahman Guyuron

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

Dean M. Toriumi
25
Postoperative Nasal Airway Obstruction . . . . . . . . 352

Mark B. Constantian and Mark G. Albert

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365

Dean M. Toriumi and Edward R. Lee
26
Alloplastic Implants for Facial Contouring. . . . . . . 373

Alan Yan and Michael J. Yaremchuk

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Edward O. Terino
27
Perioral Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . 402

Christopher D. Knotts, Byron D. Poindexter,

Robert K. Sigal, and George W. Weston

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410

Randal D. Haworth
28
Hair Restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

Alfonso Barrera

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

James E. Vogel
29
Liposuction for Body Contouring . . . . . . . . . . . . . . . 433

Simeon Wall Jr.

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451

Onelio Garcia Jr.
30
Abdominoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456

Joseph P. Hunstad and Daniel J. Krochmal

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470

Alan Matarasso and Darren M. Smith
31
Body and Extremity Contouring After

Massive Weight Loss. . . . . . . . . . . . . . . . . . . . . . . . . . . 478

Joseph F. Capella

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493

Dennis Hurwitz
32
Gluteal Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . 499

Ashkan Ghavami and Joubin S. Gabbay

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516

J. Abel de la Peña and Guillermo J. Gallardo
33
Female Aesthetic Genital Surgery. . . . . . . . . . . . . . . 521

Christopher J. Salgado, Lydia A. Fein,

Natalie R. Joumblat, and Ajani Nugent

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527

Gary J. Alter
Section V The Breast
Joseph M. Serletti and Joshua Fosnot, Associate Editors
34
Breast Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . 537
G. Patrick Maxwell and Allen Gabriel

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566

Mitchell Howard Brown, Ron B. Somogyi, and

Stephanie Hoffbauer
Contents

ix
Contents

Special Commentary: Silicone Breast Implants

Associated with Anaplastic Large Cell Lymphoma. . . 575

Garry S. Brody
35
Mastopexy and Augmentation Mastopexy. . . . . . . 581

Kenneth C. Shestak

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592

M. Bradley Calobrace
36
Reduction Mammaplasty. . . . . . . . . . . . . . . . . . . . . . 602

Sabine Lovell, Yan T. Ortiz-Pomales, and

Albert Losken

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613

Elizabeth J. Hall-Findlay
37
Gynecomastia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623

Dennis C. Hammond and Kuylhee Kim

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630

Mordcai Blau and Ron Hazani
38.
Breast Reduction with Implants. . . . . . . . . . . . . . . . 644

Amy S. Colwell

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 658

Neil A. Fine and Michelle Grim
39
Breast Reconstruction with Autologous Tissue. . . 665

Joshua Fosnot and Joseph M. Serletti

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677

Adrian S.H. Ooi and David H. Song
Volume Two
Section VI Pediatric and Craniofacial Surgery
Pravin K. Patel and Peter J. Taub, Associate Editors

PEDIATRIC
40
Cleft Lip and Cleft Palate. . . . . . . . . . . . . . . . . . . . . . . 687

Mimis N. Cohen

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719

Richard E. Kirschner and Oksana A. Jackson
41
Craniosynostosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726

Peter J. Taub and Joseph E. Losee

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735

David J. David
42
Orofacial and Craniofacial Deformities. . . . . . . . . . 739

Fernando Molina

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753

Philip Kuo-Ting Chen and Susie Lin
43
Orthognathic Surgery and Maxillofacial

Distraction Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . 759

Pravin K. Patel

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784

Joseph G. McCarthy
44
Auricular Reconstruction. . . . . . . . . . . . . . . . . . . . . . 788

Françoise Firmin and Alexandre Marchac

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804

David J. Reisberg

Special Commentary: Auricular Reconstruction:

Polyethylene Framework Technique. . . . . . . . . . . . . 808

John Reinisch and Youssef Tahiri
45
Vascular Anomalies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 811

Arin K. Greene

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819

Juan Carlos Lopez Gutierrez
46
Tissue Expansion for Pigmented Lesions and

Other Defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824

Bruce S. Bauer and Sara R. Dickie

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847

Ernest K. Manders

FACIAL TRAUMA
47
Fractures of the Jaws . . . . . . . . . . . . . . . . . . . . . . . . . . 850

Marco Rainer Kesting

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868

David E. Morris
48
Facial Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875

Karl C. Bruckman, Rizal Lim, and Joe I. Garri

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889

Jürgen Hoffmann
49
Pediatric Facial Fractures. . . . . . . . . . . . . . . . . . . . . . . 893

Seth R. Thaller and David Gerth

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908

Arun K. Gosain
50
Complex Soft Tissue and Bony Maxillofacial

Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914

Kurt Vinzenz and Christian Schaudy

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931

J. Rodrigo Diaz-Siso and Eduardo D. Rodriguez
Section VII Reconstructive Surgery for the Head and Neck, Body, and Lower Extremity
Lawrence J. Gottlieb, Associate Editor
51
Oral and Pharyngeal Reconstruction. . . . . . . . . . . . 943

Peirong Yu

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959

Mouchammed Agko and Hung Chi Chen
ix

x
52.
Reconstruction of the Mandible and Maxilla . . . . 969

Matthew M. Hanasono

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 981

Giorgio De Santis and Alessio Baccarani
53
Reconstruction of the Lip and Cheek. . . . . . . . . . . . 990

Peter C. Neligan

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998

Lawrence J. Gottlieb
54
Reconstruction of the Scalp and Cranium . . . . . . 1005

Russell R. Reid and Lawrence J. Gottlieb

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020

Salvatore C. Lettieri
55
Eyelid Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . .1025

Chris Alabiad and Bradford W. Lee

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1041

Michael Patipa
56
Facial Reanimation Surgery. . . . . . . . . . . . . . . . . . . 1045

Eyal Gur and Daniel Josef Kedar

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1057

Ronald M. Zuker
57
Reconstruction of the Chest and Abdomen. . . . . 1063

Mark W. Clemens and Charles E. Butler

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1078

Geoffrey G. Hallock
58
Lower Extremity Reconstruction. . . . . . . . . . . . . . 1085

Basel Sharaf, Karen Kim Evans, Ali Izadpanah,

and Samir Mardini

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107

L. Scott Levin
59
Microsurgical Treatment of Lymphedema. . . . . . 1113

Deana Saleh Shenaq and David W. Chang

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1122

Wei F. Chen
Section VIII The Hand and Upper Extremity
David T. Netscher and Zubin Jal Panthaki, Associate Editors
60
Congenital Hand Deformities . . . . . . . . . . . . . . . . . 1133

Andreas D. Weber, Lesley C. Butler, and

Scott N. Oishi

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1147

Joseph Upton, Brian I. Labow, and Amir Taghinia
61
Flexor Tendon Injuries. . . . . . . . . . . . . . . . . . . . . . . . 1157

Jason Wong, Wee Sim Khor, Martin Franz Langer,

and Duncan Angus McGrouther

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174

Jin Bo Tang
62
Extensor Tendon Injuries. . . . . . . . . . . . . . . . . . . . . . 1183

Wyndell H. Merritt and Collier S. Pace

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1215

Donald H. Lalonde
63
Bone and Joint Injuries: Hand, Wrist, and

Distal Radius. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1218

Francisco del Piñal

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1239

Steven L. Moran
64
Soft Tissue Coverage and Mutilating

Extremity Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247

David T. Netscher

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1263

David W. Person
65
Replantation of the Hand and Toe-to-Hand

Microsurgical Transplantation. . . . . . . . . . . . . . . . . 1266

Nidal F. AL Deek, Yu-Te Lin, and Fu Chan Wei

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1280

Luis R. Scheker
66
Peripheral Nerve Injuries and the Brachial Plexus.1282

Thomas H. Tung and Susan E. Mackinnon

Special Commentary:

Brachial Plexus Birth Injury. . . . . . . . . . . . . . . . . . . . . . . 1294

John A.I. Grossman, Andrew E. Price, Harvey Chim,

Herbert Valencia, and Leslie Agatha Grossman
67
Nerve Decompression Surgery . . . . . . . . . . . . . . . . 1300

Allen L. Van Beek, Jason D. Fowler, and Holly S. Ryan

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1310

Ivica Ducic
68
Dupuytren’s Contracture. . . . . . . . . . . . . . . . . . . . . . 1315

Zubin Jal Panthaki, Dang T. Pham, David T. Netscher,

and Sanjeev N. Puri

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1329

Todd A. Theman and Prosper Benhaim
Section IX Burns
Lawrence J. Gottlieb, Associate Editor
69
Facial Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1345

Matthias B. Donelan, Benjamin Levi,

Jonathan S. Friedstat, and Charles D. Hwang

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1355

William B. Norbury and David N. Herndon
70
Burns of the Body and Extremities. . . . . . . . . . . . . 1360

Shannon L. Wong, Alyson A. Melin, and

Debra A. Reilly

Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1376

Sigrid Blome-Eberwein
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN-1
Contents

xi
Preface
Errare humanum est, preseverare diabolicum
To err is human, but to persist (in mistake) is diabolical (stupid).
Lucius Annaeus Seneca (c. 4 BC–65 AD)
The first edition of this book was published in 1972. At
that time, acknowledgment and reporting of complications
were frowned upon due to pride and ignorance but mainly
because of fear of litigation. Twelve years later, in 1984, the
second edition was published, followed by the third edition
in 2001. Recognizing the overwhelming advances in our
specialty and the increased importance and acceptance of
patient safety in everyone’s practice, Bob and I started de­
veloping plans for a fourth edition a few years later. Unfor­
tunately these plans were interrupted due to Bob’s serious
illness, which led to his untimely death in 2010.
Despite the plethora of great publications related to
our specialty published during the last decade, there was a
recognized void in comprehensive coverage of the topic of
avoidance of unfavorable results and management of com­
plications. Yet I was reluctant to go forward with the next
edition without Bob’s presence and guidance, concerned
that I might not be able to do justice to his monumental
endeavor. As the idea was maturing in my mind, I discussed
my thoughts with my good friend Seth Thaller. He offered
valuable advice and suggestions and encouraged me to go
forward with the project. He also enthusiastically agreed to
serve as co-editor for the fourth edition.
We agreed to dedicate the book to the memory of Dr.
Robert Goldwyn, who conceived the text and edited the
three previous editions, and to retain the universally, highly
praised format of the book with chapters focusing primar­
ily on avoiding unfavorable results or complications and on
how to manage and treat them if they do occur. Each chapter,
as in the previous editions, was to be followed by a discus­
sion by an expert who would highlight and provide coun­
terpoints to further elucidate successful management of un­
toward conditions.
We were fortunate to meet Ms. Sue Hodgson. She was
fully aware of the success of the previous editions and
promised to work closely with us for the preparation of an
outstanding publication. Sue agreed to support our plans
to fully modernize the book into a two-volume format. It
would be highlighted with full-color printing throughout,
a bespoke artwork program especially created for the new
edition by the Publisher, and the addition of numerous vid­
eos in a complementary e-book version.
Because of how highly specialized plastic surgery has
become, it has become apparent we would need the par­
ticipation of more experts. So we invited several renowned
authorities to serve as associate editors in the section re­
lated to their respective areas of excellence. They actively
participated in the planning and organization of the con­
tent, the selection of an international group of highly quali­
fied and respected authors, and the critical review of the
manuscripts.
Safety in surgical practice is no longer a formality. It has
been incorporated into everyday clinical practice, education,
and board certification. Thus following the current trends
we expanded the section on legal and safety issues to in­
clude valuable information for the established practitioner
as well as the novice starting a practice. This section is fol­
lowed by presentation of cutting-edge information and an
updated list of the most commonly encountered topics in
everyday practice and beyond, recognizing that it would be
impossible to include all plastic surgery–related topics in
one publication.
The book has been designed for quick and easy reference
with color-coded sections, summary boxes, and lists of po­
tential complications. It is extensively illustrated with more
than 3,200 photographs and illustrations and comes with a
bundled e-book version so that the information can be ac­
cessed while on the road or in the operating room. More
than 100 videos are also included with technical pearls and
recommendations for avoiding and treating unfavorable re­
sults and complications.
Although overall this is a very different book from the
previous editions, it maintains intact the philosophy of those
editions as established by Dr. Goldwyn. We hope that our
readers will be pleased with the outcome and regularly em­
ploy the knowledge to improve patient care.
Mimis N. Cohen, MD, FACS, FAAP

xii
Preface to the First Edition
By its focus on unfavorable results, this text differs from
most books on plastic and reconstructive surgery because
it is devoted solely to the unpleasant realities of our spe­
cialty. It contains information that we would like to obtain
at meetings and in articles but seldom do.
Although medicine has evolved to a point at which it
acknowledges mistakes, a certain amount of hush-hush re­
mains. Formerly, pride and ignorance were the cause of this
reticence; now fear of litigation is also a factor. In many ways
this book makes plastic surgeons less vulnerable to adverse
legal proceedings, not only because its information should
upgrade our skills but also because it confronts and confirms
our fallibility. These pages strongly document the fact that
the ideal result is not always achieved. A successful result is
what most of us, if fortunate, are likely to attain. The patient
and surgeon will fare better if each understands and accepts
the risk and unpredictability of any procedure. The vagaries
of the human condition are largely responsible for this un­
predictability, and that is one reason why medicine remains
an art, no matter what its scientific accretion.
In this text the term unfavorable result refers to a se­
quela of treatment which the patient, the surgeon, or both
consider undesirable. Admittedly, what is desirable varies
according to individual standards and preferences. We pain­
fully remember the occasional patient dissatisfied with what
we judged a superior result. Yet, if we are honest, we should
also recollect the many who have been delighted with some­
thing far less than perfect, sometimes to the point of making
us feel a twinge of guilt.
The situations selected for discussion here are those
which most discerning patients and surgeons would con­
sider unfavorable.
One might object to the word result in the title because
of its implied finality. In defense I would say that not all re­
sults are necessarily final, except for death, and even this
point may be argued by some. Moreover, many chapters
nicely demonstrate that what we would consider a “bad re­
sult” need not be the end stage if we have sufficient persis­
tence and ingenuity.
An unfavorable result includes more than what complica­
tion connotes. All complications are unfavorable results, but not
all unfavorable results are complications in the usual sense of
the word. For example, a patient with a wound infection after
rhinoplasty would undoubtedly be listed among the weekly
complications of a surgical service. If this same patient had
an uneventful postoperative course but a year later bore the
flared­nostril stigma, she would have an unfavorable result (not
necessarily irrevocable) but not a complication. Yet, for the sur­
geon as well as the patient, this unhappy outcome would cause
considerable distress, even more than might arise from a com­
plication that has not left permanent damage—such as a peni­
cillin reaction or a momentary cardiac arrhythmia.
Complications and unfavorable results have here been
considered together in order to present maximal informa­
tion about clinical pitfalls. The contributing authors have not
had an easy task; aside from the usual rigors of writing for
a compulsive editor, each has had to review his experience
without blinders but with candor and completeness This
form of self-examination is masochistic and unpopular. But
we all would acknowledge the truth of the maxim, “Mis­
takes are often the best teachers.” In that regard, this book
is extremely ambitious and moderately naive: it assumes
that we can learn from the mistakes of others—not a well-
established human faculty.
Dealing with a large variety of problems, these pages
should contain something for everybody in different stages
of the learning and practice of plastic and reconstructive
surgery. Since no single volume of such a nature can be
all-inclusive, there are lacunae—not too conspicuous, it is
hoped, or too numerous.
The book should also stimulate a review of our thought
processes in treating a patient. One will soon realize what
complex measures he takes, consciously and unconsciously,
to avoid an unwanted outcome in achieving the surgical objec­
tive. This chess player’s mentality is discernible at every step
in the therapy, from the first encounter to the last good-bye.
R.M.G.

xiii
Preface to the Second Edition
It is not enough to have carried out an operation skillfully: it is just as important to foresee and
to prevent the complications that may follow it.
Dominique-Jean Larrey
…The best surgeon, like the best general, is he who makes the fewest mistakes.
Astley Paston Cooper
More than a decade has passed since the first edition of this
book was published. During this interval, significant events
have occurred in plastic surgery. One immediately thinks of
the now routine application of microsurgery to reimplanta­
tion and transplantation, the burgeoning numbers of cranio­
facial procedures, and the common use of musculocutane­
ous flaps. Our specialty has become so specialized that the
general plastic surgeon is extinct. I know no one who in fact
or fantasy does with equal skill and frequency craniofacial
operations, microsurgery, repair of clefts and hypospadias,
head and neck work, cosmetic procedures, and hand cases.
Because of the breadth and depth of plastic surgery, no sin­
gle volume could realistically include every possible unde­
sirable outcome, with its prevention and treatment.
Unlike 15 years ago, unfavorable results are now dis­
cussed openly both in meetings and in print. This change
from the hush-hush of the past has come as the plastic sur­
geon’s susceptibility to malpractice suits has increased. Al­
though at first thought one might consider this phenomenon
a paradox, it is not. The explanation is the cogency of real­
ity and the necessity for a profession and those it serves to
deal with events as they are. It is preferable that a surgeon
and a patient comprehend the reality before operation; then
any complication will have been anticipated if not expected.
When the realization first comes postoperatively, it is unset­
tling, even astonishing, leaving the patient feeling betrayed
and angry and the surgeon bewildered and defensive.
It was said that the greatness of Caesar lay in his “not
expecting the plum tree to give forth peaches.” That not
every treatment culminates in success is so well known
that it seems unnecessary to mention. Yet it is surprising
how frequently this surgeon manages to expect the next
operation to give a perfect result. Depending on the ob­
server’s vantage point, this attitude has been called opti­
mistic, vain, grandiose, arrogant, stupid, or negligent, or a
combination thereof.
This book, then, is devoted to the unpleasant side of
our specialty. It is part of our professional life but not all
of it, no more than a funeral is the story of a life. Death,
disease, and displeasure are realities, however, with which
all humans must contend. For most of our lives, we sur­
geons meet these unwanted circumstances more often
in others but, alas, we find them ultimately in ourselves.
Wherever initiative or chance leads us, we will eventu­
ally encounter reality. Enlarging the surgeon’s percep­
tion of reality is a major objective of these pages. I have
long pleaded that we report our professional acts, opera­
tive or not, in terms of the entire spectrum: best, average,
and worst results, the last being the focus of this book.
Without adequate information, we shall engender within
ourselves fanciful expectations that we will transmit un­
knowingly to our patients.
R.M.G.

xiv
Preface to the Third Edition
This third edition comes 28 years after the first and 16 years
after the second. During those intervals, significant ad­
vances occurred in plastic surgery and in all medical disci­
plines. We now can do more for patients. Yet inevitably, un­
favorable results, minor and major, still occur. This edition,
like its predecessors, concerns these unpleasant realities.
When I was gathering material about complications for
the first edition, I reported my own and enlisted others to
do the same. A few senior plastic surgeons advised me to
desist because they feared the medicolegal repercussions
for our specialty and the personal consequences for my­
self if my name were to be forever linked to bad outcomes.
Fortunately, perhaps miraculously, these predictions have
proven false. In fact, attorneys for defendants have used
this information to demonstrate to juries that a complica­
tion for which their client has been charged with negligence
has been well described. Patients still come to me despite
a reputation built partially on failed procedures, luckily not
all mine.
By custom, this preface should have been written by
both editors, Mimis Cohen and myself. As the (consider­
ably) senior editor, I prevailed on him to let me author it
because I wasted to praise and thank him for this constant
enthusiasm, his prodigious work, and his sage counsel. If I
had not enlisted him – and if he had not graciously agreed –
this third edition would likely not have appeared. In this en­
deavor, as in my entire professional life, I have been blessed
and am truly grateful.
We both appreciate more than we can express the labors
of the contributing authors and discussants whose book this
really is. We also want to thank the highly skilled profes­
sionals at Lippincott Williams & Wilkins who helped make
this book possible, including Beth Barry, Joanne Bersin, Tony
DeGeorge, Penny Bice, and Allison Risko.
Robert M. Goldwyn, MD

xv
Acknowledgments
Compiling a textbook involving the full breadth of our spe­
cialty and including an array of formidable authors can be
a daunting challenge. Add to this the task of compiling and
organizing an outstanding international team of experts
committed to re-create and/or update the third edition of
an iconic and novel opus conceived by such an outstand­
ing individual as Dr. Robert Goldwyn, proved to be a mam­
moth, truly herculean effort. We hope we have been able to
successfully reinvigorate Dr. Goldwyn’s landmark contribu­
tion, The Unfavorable Results in Plastic Surgery: Avoidance
and Treatment, and we would like to briefly recognize all
the individuals who were instrumental in the completion
of this project.
In order to achieve the best possible outcome, we en­
listed the participation of highly qualified and talented ex­
perts in their field to serve as associate editors for each of
the sections of the book. They provided us with invaluable
advice regarding titles of chapters and prospective authors.
Each submitted excellent contributions within their sections
but also reviewed most of their section’s manuscripts and
revised them, as needed. We are grateful to Dr. David Birn­
bach for his participation in the section of Legal and Safety
Issues; Dr. Linda Philips for General Problems; Dr. James
Stuzin for Aesthetic Surgery; Drs. Joseph Serletti and Joshua
Fosnot for The Breast; Drs. Pravin Patel and Peter Taub for
Pediatric and Craniofacial Surgery; Dr. Lawrence Gottlieb
for Reconstructive Surgery of the Head and Neck, Body, and
Lower Extremity and Burns; and Drs. David Netscher and
Zubin Panthaki for Hand and Upper Extremity. We would
have never been able to successfully complete this project
without their phenomenal contributions.
Our colleagues and renown experts, drawn both nation­
ally and internationally, volunteered to participate as con­
tributing authors or discussants. They prepared exceptional
chapters that required thoughtful insight into the specific
aspects of plastic surgery, namely unfavorable results. Delv­
ing into what can be a deeply personal and sensitive subject
requires deep soul searching and courage. They shared their
extensive experience and insight on the prevention, recog­
nition, and management of unfavorable results. In addition,
many furnished technical videos to further complement the
educational value of their contributions. We deeply appre­
ciate their involvement and their time and effort in accom­
plishing our goals.
Our office assistants, Erin McGinn and Teresa Shipman,
helped keep us on track. They coordinated and participated
in the numerous conference calls through the course of de­
velopment, and they actively participated in the preparation
of lists, correspondence with authors and the publisher, con­
firmation of assignments, and the overall smooth interaction
with our publisher.
We are indebted to the archeologists and staff of the
National Archeological Museum in Athens, The Acropolis
Museum in Athens, and the museums in Corinth, Herak­
leion, and Delos for the guidance and assistance in the se­
lection of representative artwork to complement this pub­
lication.
From the beginning, we wish to acknowledge the fore­
sight and perseverance of our Editor Sue Hodgson. Even
though the name of the publisher changed not once, twice,
but three times, this never swayed our fearless leader. She
continued pushing forward to completion. Her efforts and
guidance were truly exceptional. We would also like to thank
Developmental Editor Kathleen Sartori who kept the project
moving and took care of the many details. A special thank
you to our Art Director Brenda Bunch, our copyeditor Kelly
Mabie, and the entire production team in St. Louis and New
York. Their expertise and dedication to publishing attractive
and accurate books are second-to-none.
We must not forget to acknowledge our patients. They
allow each of us, as plastic surgeons, to practice our specialty
every day. Their trust in us as makes going to work each day
a pleasure and not a mundane task. The knowledge gained
from them and the content from the book The Unfavorable
Result in Plastic Surgery will hopefully benefit many more
patients in the generations to come.
Mimis N. Cohen, MD, FACS, FAAP
Seth R. Thaller, MD, DMD, FACS
Cover Image: “Head of Goddess.” Courtesy Acropolis Museum, Athens, Greece. Photo: Socrates Mavromatis. ©
Acropolis Museum, ­Athens, Greece.

xvi
Contributors
Mouchammed Agko, MD
Fellow in Microsurgery
Department of Plastic and Reconstructive Surgery
China Medical University Hospital
Taichung, Taiwan
Chris Alabiad, MD, FACS
Associate Professor of Clinical Ophthalmology
Assistant Dean for Student Affairs
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Miami, Florida
Mark G. Albert, MD
Program Director
Aesthetic Plastic Surgery Fellowship
Manhattan Eye, Ear, and Throat Hospital
New York, New York
Gary J. Alter, MD
Assistant Clinical Professor of Plastic Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California
Alessio Baccarani, MD, FACS
Senior Staff Surgeon
Department of Plastic Surgery
Modena University Hospital
Modena, Italy
Thomas J. Baker, MD
Voluntary Professor
Division of Plastic Surgery
DeWitt Daughtry Family Department of Surgery
Department of Surgery
University of Miami Miller School of Medicine
Jackson Memorial Hospital
Miami, Florida
Alfonso Barrera, MD, FACS
President
The Texas Society of Plastic Surgeons
Clinical Assistant Professor
Department of Plastic Surgery
Baylor College of Medicine
Houston, Texas
David R. “Chip” Barry, Jr., JD
Partner
Corboy & Demetrio P.D.
Chicago, Illinois
Lawrence S. Bass, MD, FACS
Clinical Assistant Professor of Plastic Surgery
Hofstra Northwell School of Medicine
Department of Plastic Surgery
Lenox Hill/Manhattan Eye, Ear and Throat Hospital
New York, New York
Bruce S. Bauer, MD, FACS, FAAP
Director of Pediatric Plastic Surgery
NorthShore University HealthSystem
Highland Park Hospital
Clinical Professor of Surgery
The University of Chicago Pritzker School of Medicine
Chicago, Illinois
Prosper Benhaim, MD, FACS
Chief of Hand Surgery
Associate Professor
Department of Orthopaedic Surgery
Division of Plastic and Reconstructive Surgery
University of California, Los Angeles, Ronald Reagan
  Medical Center
Los Angeles, California
David J. Birnbach, MD, MPH
Professor and Vice Provost
University of Miami Miller School of Medicine
Director
Jackson Memorial Hospital Center for Patient Safety
Miami, Florida
Mordcai Blau, MD, PC
Attending Physician
Plastic Surgery
White Plains Hospital
White Plains, New York
Sigrid Blome-Eberwein, MD
Plastic Surgeon
Regional Burn Center
Lehigh Valley Health Network
Allentown, Pennsylvania
Cristiano Boneti, MD
Assistant Professor
Plastic Surgery and Oncology
University of Miami Miller School of Medicine
Miami, Florida
Garry S. Brody, MD, MSc
Professor Emeritus
Plastic Surgery
University of Southern California
Los Angeles, California

xvii
Contributors
Philip Kuo-Ting Chen, MD
Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital and Chang Gung University
  Medical College
Taoyuan, Taiwan
Director
Craniofacial Center
Chang Gung Memorial Hospital
Taipei, Taiwan
Wei F. Chen, MD, FACS
Assistant Professor
Division of Plastic and Reconstructive Surgery
Director
Center for Lymphedema Research and Reconstruction
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Harvey Chim, MD
Associate Professor
Division of Plastic and Reconstructive Surgery
University of Florida College of Medicine
Gainesville, Florida
Mark W. Clemens, MD, FACS
Assistant Professor
Department of Plastic Surgery
MD Anderson Cancer Center
University of Texas
Houston, Texas
Abigail M. Cochran, MD
Assistant Professor
Institute for Plastic Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Mimis N. Cohen, MD, FACS, FAAP
Professor and Chief
Division of Plastic, Reconstructive, and Cosmetic Surgery
Director, Craniofacial Center
University of Illinois
Chicago, Illinois
Sydney R. Coleman, MD
Clinical Assistant Professor of Plastic Surgery
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
New York, New York
Amy S. Colwell, MD, FACS
Associate Professor
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Mitchell Howard Brown, MD, MEd, FRCSC
Plastic and Reconstructive Surgeon
Associate Professor
Department of Surgery
University of Toronto
Toronto, Ontario, Canada
Karl C. Bruckman, MD, DDS
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
New York, New York
Charles E. Butler, MD, FACS
Chairman and Professor
Charles B. Barker Endowed Chair in Surgery
Department of Plastic Surgery
MD Anderson Cancer Center
University of Texas
Houston, Texas
Lesley C. Butler, MPH
Senior Clinical Research Coordinator
Department of Orthopaedics
Texas Scottish Rite Hospital for Children
Dallas, Texas
M. Bradley Calobrace, MD
Calobrace and Mizuguchi Plastic Surgery Center
Clinical Faculty
Department of Surgery
Division of Plastic Surgery
University of Louisville
Louisville, Kentucky
University of Kentucky
Lexington, Kentucky
Joseph F. Capella, MD
Chief
Post-bariatric Body Contouring
Division of Plastic Surgery
Hackensack University Medical Center
Hackensack, New Jersey
David W. Chang, MD, FACS
Professor of Surgery
Department of Plastic and Reconstructive Surgery
The University of Chicago
Chicago, Illinois
Hung Chi Chen, MD, PhD, FACS
Professor of Plastic Surgery
Department of Plastic and Reconstructive Surgery
China Medical University Hospital
International Medical Center
Taichung, Taiwan

xviii
Contributors
Sara R. Dickie, MD
Clinical Associate
Department of Surgery
Section of Plastic and Reconstructive Surgery
The University of Chicago Hospitals
Chicago, Illinois
Director of Plastic Surgery
Illinois Dermatology Institute, LLC
Buffalo Grove, Illinois
Matthias B. Donelan, MD
Associate Professor
Harvard Medical School
Chief of Staff
Shriners Hospital for Children
Boston, Massachusetts
Ivica Ducic, MD, PhD
Professor of Surgery (Clinical)
The George Washington University
Washington Nerve Institute
McLean, Virginia
Karen Kim Evans, MD
Medstar Georgetown University Hospital
Washington, DC
Lydia A. Fein, MD, MPH
Post Graduate Year 3
Department of Obstetrics and Gynecology
University of Miami Miller School of Medicine
Jackson Memorial Hospital
Miami, Florida
Julius W. Few Jr., MD
Plastic Surgeon
The Few Institute for Aesthetic Plastic Surgery
Clinical Professor of Surgery
Division of Plastic Surgery
The University of Chicago Pritzker School of Medicine
Health Science Clinician
Northwestern Memorial Hospital
Chicago, Illinois
Neil A. Fine, MD
President
Northwestern Specialists in Plastic Surgery
Chicago, Illinois
Nicholas A. Fiore II, MD, FACS
President
Fiore Hand and Wrist
Houston, Texas
Mark B. Constantian, MD, FACS
Surgeon
Department of Surgery (Plastic Surgery)
St. Joseph Hospital
Nashua, New Hampshire
Adjunct Clinical Professor
The Division of Plastic Surgery
Department of Surgery
University of Wisconsin School of Medicine and
  Public Health
Madison, Wisconsin
Visiting Professor
Department of Plastic Surgery
University of Virginia School of Medicine
Charlottesville, Virginia
David J. David, MD, FRCS, FRACS
Professor
Australian Craniofacial Unit
Women’s and Children’s Hospital
North Adelaide, South Australia
Nidal F. AL Deek, MSc, MD
Center for Vascularized Composite Allotransplantation
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taipei, Taiwan
Chang Gung University Medical College
Taoyuan, Taiwan
J. Abel de la Peña, MD, FACS
Director
Plastic Surgery
Institute for Plastic Surgery
Hospital Angeles De Las Lomas
Mexico City, Mexico
Francisco del Piñal, MD, PhD
Hand-Wrist and Plastic Surgery
Private Practice
Madrid, Spain
Giorgio De Santis, MD
Professor of Plastic Surgery
Department of Plastic Surgery
University of Modena and Reggio Emilia
Modena, Italy
J. Rodrigo Diaz-Siso, MD
Professor
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
New York, New York

xix
Warren Garner, MD
Professor of Surgery
Program Director of Plastic Surgery
Director
Los Angeles County and University of Southern California
  Regional Burn Center
Los Angeles, California
Joe I. Garri, MD, DMD
Voluntary Clinical Faculty
Department of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
David Gerth, MD
Resident Physician
Department of Surgery
Division of Plastic, Aesthetic and Reconstructive Surgery
University of Miami Miller School of Medicine
Miami, Florida
Ashkan Ghavami, MD
Assistant Clinical Professor
Department of Plastic Surgery
David Geffen University of California, Los Angeles,
  School of Medicine
Los Angeles California
President, Plastic Surgery
Ghavami Plastic Surgery
Beverly Hills, California
Robert M. Goldwyn (deceased)
Kenneth W. Goodman, PhD
Professor and Director
Institute for Bioethics and Health Policy
University of Miami Miller School of Medicine
Miami, Florida
Arun K. Gosain, MD
Children’s Service Board Professor
Chief, Division of Pediatric Plastic Surgery
Ann & Robert H. Lurie Children’s Hospital of Chicago
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Lawrence J. Gottlieb, MD, FACS
Professor of Surgery
Director of Burn & Complex Wound Center
Section of Plastic and Reconstructive Surgery
The University of Chicago Medicine & Biological Sciences
Chicago, Illinois
Mark S. Granick, MD, FACS
Professor Chief of Plastic Surgery
Division of Plastic Surgery
Department of Surgery
Rutgers New Jersey Medical School
Newark, New Jersey
Françoise Firmin, MD
Plastic and Reconstructive Surgery
Clinique Bizet
Paris, France
Joshua Fosnot, MD
Assistant Professor
Department of Surgery
Division of Plastic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Jason D. Fowler, MD, PhD
Plastic and Reconstructive Surgery Resident
Department of Plastic Surgery
University of Minnesota
Minneapolis, Minnesota
Jonathan S. Friedstat, MD
Instructor
Division of Burn Surgery
Department of Surgery
Harvard Medical School
Boston, Massachusetts
David Kenneth Funt, MD, FACS
Assistant Clinical Professor of Plastic Surgery
Icahn School of Medicine at Mount Sinai
New York, New York
Joubin S. Gabbay, MD
Surgeon
Gabbay Plastic Surgery
Beverly Hills, California
Allen Gabriel, MD, FACS
Clinical Associate Professor of Plastic Surgery
Peacehealth Plastic Surgery
Vancouver, Washington
Guillermo J. Gallardo, MD
Plastic and Reconstructive Surgeon
Plastic Surgery Institute
Hospital Ángeles Lomas
México City, México
Onelio Garcia Jr., MD, FACS
Voluntary Assistant Professor
Division of Plastic Surgery
University of Miami Miller School of Medicine
Chief of Plastic Surgery
Palmetto General Hospital
Miami, Florida
Contributors

xx
Elizabeth J. Hall-Findlay, MD, FRCSC
Surgeon
Banff Plastic Surgery
Banff, Alberta, Canada
Geoffrey G. Hallock, MD
Consultant in Plastic Surgery
Department of Surgery
Sacred Heart Hospital
Allentown, Pennsylvania
Dennis C. Hammond, MD
Associate Program Director
Department of Plastic and Reconstructive Surgery
Spectrum Health/Michigan State University
Grand Rapids, Michigan
Matthew M. Hanasono, MD
Professor
The University of Texas M.D. Anderson Cancer Center
Houston, Texas
Ahmed M. Hashem, MD
Fellow Aesthetic Plastic Surgery
Department of Surgery
Cleveland Clinic
Cleveland, Ohio
Assistant Professor
Department of Plastic Surgery
Cairo University
Cairo, Egypt
Randal D. Haworth, MD, FACS
Chief
Haworth Institute
Beverly Hills, California
Ron Hazani, MD, FACS
Plastic Surgeon
Private Practice
Beverly Hills, California
Associate Member
Department of Surgery
Cedars-Sinai Medical Center
Los Angeles, California
David N. Herndon, MD
Professor and Director of Research
University of Texas Medical Branch and Shriners
  Hospitals for Children
Galveston, Texas
Stephanie Hoffbauer, BHSc (PA)
Department of Surgery
University of Toronto
Toronto, Ontario, Canada
Arin K. Greene, MD, MMSc
Surgeon
Vascular Anomalies Center
Department of Plastic and Oral Surgery
Boston Children’s Hospital
Associate Professor
Harvard Medical School
Boston, Massachusetts
Michelle Grim, PA-C
Northwestern Specialists in Plastic Surgery
Chicago, Illinois
John A.I. Grossman, MD, FACS
Assistant Clinical Professor of Surgery
University of Miami Miller School of Medicine
Attending Surgeon
Miami Children’s Hospital
Founding Director
Brachial Plexus Program
Miami Children’s Hospital
Miami, Florida
Leslie Agatha Grossman
Former Research Assistant
Brachial Plexus Program
Miami Children’s Hospital
Miami, Florida
Eyal Gur, MD
Professor of Surgery
Sackler Faculty of Medicine
The Tel Aviv University
Chief
The Plastic and Reconstructive Surgery Department
The Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
Juan Carlos Lopez Gutierrez
Director
Vascular Anomalies Center
La Paz Children’ s Hospital
Associate Professor of Pediatrics
University Autonoma of Madrid Spain
Madrid, Spain
Karol A. Gutowski, MD, FACS
Adjunct Associate Professor of Surgery
Department of Surgery
University of Illinois at Chicago
Chicago, Illinois
Bahman Guyuron, MD, FACS
Emeritus Professor
Department of Plastic Surgery
Case Western Reserve University
Cleveland, Ohio
Contributors

xxi
Marco Rainer Kesting, MD, DMD
Professor
Department of Oral and Maxillofacial Surgery
Klinikum rechts der Isar
Munich University of Technology
Munich, Bavaria, Germany
Geoffrey R. Keyes, MD, FACS
Clinical Associate Professor of Plastic Surgery
Division of Plastic Surgery
Keck School of Medicine of University of Southern
  California
Los Angeles, California
Wee Sim Khor, BSc MBChB MRCS(Ed)
Specialist Registrar
Department of Plastic and Reconstructive Surgery
University Hospital South Manchester
Manchester, England, United Kingdom
Kuylhee Kim, MD
Aesthetic and Reconstructive Breast Fellow
Partners in Surgery
Grand Rapids, Michigan
Richard E. Kirschner, MD, FAAP, FACS
Chief
Plastic and Reconstructive Surgery
Director
Cleft Lip and Palate-Craniofacial Center
Nationwide Children’s Hospital
Professor
Department of Plastic Surgery
The Ohio State University Medical College
Columbus, Ohio
Christopher D. Knotts, MD, FACS
Austin-Weston Center for Cosmetic Surgery
Reston, Virginia
Vasanth S. Kotamarti, BS
Medical Student
Division of Plastic Surgery
Department of Surgery
Rutgers New Jersey Medical School
Newark, New Jersey
Daniel J. Krochmal, MD
Surgeon
MAE Plastic Surgery
Northbook, Illinois
Brian I. Labow, MD
Associate Professor of Surgery
Department of Plastic Surgery
Harvard Medical School
Boston Children’s Hospital
Boston, Massachusetts
Jürgen Hoffmann, MD, DMD, PhD, FEBOMFS
Professor and Chairman
Department of Oral and Cranio-Maxillofacial Surgery
University Hospital Heidelberg
Heidelberg, Germany
Joseph P. Hunstad, MD, FACS
Surgeon
HK Plastic Surgery
Huntersville, North Carolina
Dennis Hurwitz, MD
Director of the Hurwitz Center for Plastic Surgery
Clinical Professor of Plastic Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Charles D. Hwang, BS
Medical Student
Section of Plastic Surgery
University of Michigan Health System
Ann Arbor, Michigan
Ali Izadpanah, MD
Assistant Professor
University of Montreal
Hospital Notre Dame
Montreal, Quebec, Canada
Oksana A. Jackson, MD
Assistant Professor
Division of Plastic and Reconstructive Surgery
The Perelman School of Medicine at the University of
  Pennsylvania
Co-Director
Cleft Lip and Palate Program
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Natalie R. Joumblat, BS
Research Associate 1
Department of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
Daniel Josef Kedar, MD
Surgeon
The Plastic and Reconstructive Surgery Department
The Tel Aviv Sourasky Medical Center
Sackler Faculty of Medicine
The Tel Aviv University
Tel Aviv, Israel
Sheri A. Keitz, MD, PhD
Chief
Division General Internal Medicine
Vice Chair for Clinical Affairs
Department of Medicine
UMass Memorial Health Care and University of
  Massachusetts Medical School
Worcester, Massachusetts
Contributors

xxii
Rizal Lim, MD
Cranofacial Surgeon
Burn and Reconstructive Centers of Florida
Miami, Florida
Yu-Te Lin, MD, MS
Center for Vascularized Composite Allotransplantation
Department of Plastic Surgery
Chang Gung Memorial Hospital
Taipei, Taiwan
Chang Gung University Medical College
Taoyuan, Taiwan
Susie Lin, DDS, MD
Assistant Professor
Department of Oral and Maxillofacial Surgery
Vanderbilt University Medical Center
Nashville, Tennessee
William C. Lineaweaver, MD, FACS
Medical Director
JMS Burn and Reconstruction Center
Chief of Surgery
Merit Central Hospital
Jackson, Mississippi
Joseph E. Losee, MD
Ross H. Musgrave Professor of Pediatric Plastic Surgery
Executive Vice Chair
Department of Plastic Surgery
University of Pittsburgh Medical Center
Division Chief
Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania
Albert Losken, MD, FACS
Professor
Division of Plastic and Reconstructive Surgery
Emory University
Atlanta, Georgia
Sabine Lovell, MD
General Surgery Resident
Department of General Surgery
Emory University School of Medicine
Atlanta, Georgia
Susan E. Mackinnon, MD, FRCS, FACS
Sydney M. Shoenberg Jr. and Robert H. Shoenberg Professor
Surgery Chief
Department of Plastic and Reconstructive Surgery
Washington University School of Medicine
Barnes-Jewish Hospital
St. Louis, Missouri
Ernest K. Manders, MD, FACS
Professor of Plastic Surgery
Department of Plastic Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Donald H. Lalonde
Professor of Surgery
Division of Plastic and Reconstructive Surgery
Dalhousie University
St. John, New Brunswick, Canada
Val Lambros, MD
Clinical Professor of Surgery
University of California–Irvine
Irvine, California
Martin Franz Langer, MD, PhD
Professor
Clinic for Trauma, Hand, and Reconstructive Surgery
University Clinic Muenster
Muenster, Germany
Bradford W. Lee, MD, MSc
Assistant Professor of Clinical Ophthalmology
Division of Oculofacial Plastic and Reconstructive Surgery
Department of Ophthalmology
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Miami, Florida
Edward R. Lee, MD
Resident Surgeon
Department of Otolaryngology–Head and Neck Surgery
University of Illinois
Chicago, Illinois
Raphael C. Lee, MD, ScD, FACS
Paul S. and Allene T. Russell Professor
Departments of Surgery, Medicine, Anatomy and
  Organismal Biology
Bucksbaum Institute Senior Clinical Scholar
Fellow, Institute for Molecular Engineering
The University of Chicago
Chicago, Illinois
Salvatore C. Lettieri, MD
Surgeon
Division of Plastic and Reconstructive Surgery
Mayo Clinic
Rochester, Minnesota
Benjamin Levi, MD, FACS
Assistant Professor of Surgery
Section of Plastic Surgery
Department of Surgery
University of Michigan Health System
Ann Arbor, Michigan
L. Scott Levin, MD, FACS
Paul B. Magnuson Professor
Chairman of the Department of Orthopaedic Surgery
Professor of Surgery
Division of Plastic Surgery
Perelman School of Medicine at the University of
  Pennsylvania
Philadelphia, Pennsylvania
Contributors

xxiii
Jillian M. McLaughlin, MD
Resident
Division of Plastic Surgery
Department of Surgery
University of Texas Medical Branch
Galveston, Texas
Alyson A. Melin, DO
Chief Resident in General Surgery
Department of Plastic Surgery
University of Nebraska Medical Center
Omaha, Nebraska
Wyndell H. Merritt, MD, FACS
Clinical Professor of Plastic Surgery
Department of Surgery
Virginia Commonwealth University
Richmond, Virginia
Clinical Professor of Surgery
Department of Plastic Surgery
University of Virginia
Charlottesville, Virginia
Fernando Molina, MD
Professor of Plastic Surgery
“Fernando Ortiz Monasterio” Foundation for
  Craniofacial Anomalies
Hospital Angeles del Pedregal and Postgraduate
  Division, School of Medicine
Universidad la Salle
Mexico City, Mexico
Steven L. Moran, MD
Professor and Chair
Division of Plastic Surgery
Professor
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
David E. Morris, MD, FACS
Associate Professor
Division of Plastic, Reconstructive & Cosmetic Surgery
University of Illinois at Chicago
Chicago, Illinois
Donald S. Mowlds, MD, MBA
Resident Physician
Department of Plastic Surgery
University of California–Irvine
Irvine, California
Foad Nahai, MD, FACS
Maurice J. Jurkiewicz Chair and Professor of Surgery
Department of Surgery
Emory University
Atlanta, Georgia
Mitchell Manway, DO
Research Fellow
Center for Cosmetic Enhancement
Center for Clinical and Cosmetic Research
Aventura, Florida
Alexandre Marchac, MD
Plastic and Reconstructive Surgery
Hôpital Européen Georges Pompidou
Paris, France
Samir Mardini, MD
Professor of Surgery
Mayor Clinic College of Medicine
Program Director, Plastic Surgery
Mayo Clinic
Rochester, Minnesota
Timothy J. Marten, MD, FACS
Marten Clinic of Plastic Surgery
San Francisco, California
Alan Matarasso, MD, FACS
Clinical Professor of Surgery
Hofstra University Northwell School of Medicine
New York, New York
G. Patrick Maxwell, MD
Founder
Aesthetic Surgeon
Maxwell Aesthetics
Nashville, Tennessee
Riccardo F. Mazzola, MD
Professor of Plastic Surgery
Department of Clinical Sciences and Community Health
Maxillofacial and Otolaryngology
Department of Scienze Chirurgiche Specialistiche
University of Milan
Milan, Italy
Joseph G. McCarthy, MD
Lawrence D. Bell Professor of Plastic Surgery
Professor Emeritus of Plastic Surgery
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
New York, New York
Timothy B. McDonald, MD, JD
Faculty at Loyola University School of Law
Chicago, Illinois
Duncan Angus McGrouther, MBChB, MSc, MD,
  FRCS, FMedSci.
Professor
Duke - National University of Singapore Medical School
Senior Consultant Hand Surgeon
Department of Hand Surgery
Singapore General Hospital
Singapore
Contributors

xxiv
Michael P. Ogilvie, MD, MBA
Aesthetic Surgery Fellow
The Few Institute for Aesthetic Plastic Surgery
Chicago, Illinois
Scott N. Oishi, MD, FACS
Professor
Departments of Plastic Surgery and Orthopaedic Surgery
University of Texas Southwestern Medical School
Director, Hand Services
Charles E. Seay Jr. Hand Center
Texas Scottish Rite Hospital for Children
Dallas, Texas
Adrian S.H. Ooi, MBBS (London), MRCS (Edin),
  MMed (Surg), FAMS
Plastic Surgeon
Singapore General Hospital
SingHealth/Duke-NUS Head and Neck Centre
Singapore, Republic of Singapore
Dennis P. Orgill, MD, PhD
Division of Plastic Surgery
Brigham and Women’s Hospital
Professor of Surgery
Harvard Medical School
Boston, Massachusetts
Yan T. Ortiz-Pomales, MD, FACS
LCDR, United States Navy
Plastics and Reconstructive Surgery Fellow
Emory University School of Medicine
Atlanta, Georgia
Collier S. Pace, MD
Resident Physician
Division of Plastic and Reconstructive Surgery
Virginia Commonwealth University Medical Center
Richmond, Virginia
John T. Paige, MD
Professor of Clinical Surgery
Department of Surgery
Louisiana State University Health New Orleans School
  of Medicine
New Orleans, Louisiana
Zubin Jal Panthaki, B. Eng. (Hons, Elec.), MD, CM, FACS
Professor of Clinical Surgery
Department of Plastic Surgery
Professor of Orthopaedics
Department of Surgery
University of Miami Miller School of Medicine
Miami, Florida
Paige Paparone, DO
Center for Cosmetic Enhancement
Center for Clinical and Cosmetic Research
Aventura, Florida
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Director
Center for Reconstructive Surgery
Department of Surgery
University of Washington Medical Center
Seattle, Washington
Mark S. Nestor, MD, PhD
Director, Center for Cosmetic Enhancement
Director, Center for Clinical and Cosmetic Research
Aventura, Florida
Voluntary Associate Professor
Department of Dermatology and Cutaneous Surgery
Department of Surgery, Division of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
David T. Netscher, MD
Professor
Department of Orthopedic Surgery and Division of
  Plastic Surgery
Baylor College of Medicine
Adjunct Professor of Clinical Surgery
Houston Methodist Hospital/Weill Cornell Medical College
Houston, Texas
Michael W. Neumeister, MD
Professor and Chairman
Department of Surgery
The Elvin G. Zook Endowed Chair in Plastic Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Milomir Ninkovic, MD, PhD
Professor of Plastic Surgery
Chairman
Department of Plastic, Reconstructive, Hand, &
  Burn Surgery
Academic Hospital Munich Bogenhausen
Technical University Munich
Munich, Germany
William B. Norbury, MD
Assistant Professor
Division of Plastic Surgery
Department of Surgery
The University of Texas Medical Branch
Staff Surgeon
Shriners Hospital for Children
Galveston, Texas
Ajani Nugent, MD
PGY-6 Resident
Division of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
Christopher L. Nuland, PA
Managing Partner
Law Offices of Christopher L. Nuland, PA
Jacksonville, Florida
Contributors

xxv
Sanjeev N. Puri, MD
Hand Surgery Fellow
Division of Plastic Surgery
Department of Surgery
University of Miami Miller School of Medicine
Miami, Florida
Russell R. Reid, MD, PhD
Professor of Surgery
Bernard Sarnat Scholar of Craniofacial Research
The University of Chicago Medicine
Chicago, Illinois
Debra A. Reilly, MD, FACS
Professor of Surgery
Department of Plastic Surgery
University of Nebraska Medical Center
Omaha, Nebraska
John Reinisch, MD
Professor of Surgery
Keck School of Medicine
University of Southern California
Director
Craniofacial and Pediatric Plastic Surgery
Cedars-Sinai Medical Center
Beverly Hills, California
David J. Reisberg, DDS, FACP, FAAMP
Professor
Department of Surgery
Director
Dental Unit/Prosthodontics and Maxillofacial Prosthetics
The Craniofacial Center (MC588)
University of Illinois Hospital and Health Sciences System
Chicago, Illinois
Neal R. Reisman, MD, JD, FACS
Clinical Professor, Plastic Surgery
Baylor College of Medicine
Chief
Department of Plastic Surgery
CHI St. Luke’s Health—Baylor St. Luke’s Medical Center
Houston, Texas
Enrico Robotti, MD
Chief of Plastic Surgery
Ospedale Papa Giovanni XXIII
Past President
Italian Society of Plastic Surgery
President Elect
Rhinoplasty Society of Europe
Bergamo, Italy
Eduardo D. Rodriguez, MD, DDS
Chair, Hansjörg Wyss Department of Plastic Surgery
Helen L. Kimmel Professor of Reconstructive Plastic Surgery
New York University Langone Medical Center
New York, New York
Pravin K. Patel, M.D., F.A.C.S.
Professor of Surgery
Chief of Pediatric Plastic and Craniofacial Surgery
The Craniofacial Center
Division of Plastic, Reconstructive and Cosmetic Surgery
University of Illinois at Chicago
Chicago, Illinois
Michael Patipa, MD
Oculoplastic Surgeon
West Palm Beach, Florida
David W. Person, MD, FACS
Managing Partner
Fellowship Director
The Hand Center of San Antonio
San Antonio, Texas
Dang T. Pham, MD
Resident
Department of General Surgery
Houston Methodist Hospital/Weill Cornell Medical College
Houston, Texas
Linda G. Phillips, MD
Truman G. Blocker, Jr., MD, Distinguished Professor
  and Chief
Division of Plastic Surgery
Department of Surgery
University of Texas Medical Branch
Galveston, Texas
Byron D. Poindexter, MD
Austin-Weston Center for Cosmetic Surgery
Reston, Virginia
Heather M. Polonsky, BS
Project Director
Center for Obesity Research and Education
Temple University College of Public Health
Philadelphia, Pennsylvania
Jason N. Pozner, MD, FACS
Director
Sanctuary Plastic Surgery
Adjunct Clinical Faculty
Department of Plastic Surgery
Cleveland Clinic Florida
Weston, Florida
Andrew E. Price, MD
Surgeon
Brachial Plexus Program
Miami Children’s Hospital
Miami, Florida
Associate Professor of Orthopedic Surgery
Hospital for Joint Diseases
New York University Langone Medical Center
New York, New York
Contributors

xxvi
Basel Sharaf, MD, FACS
Assistant Professor of Surgery
Mayo Clinic College of Medicine
Division of Plastic Surgery
Rochester, Minnesota
Deana Saleh Shenaq, MD
Resident in Plastic and Reconstructive Surgery
Section of Plastic and Reconstructive Surgery
Department of Surgery
The University of Chicago
Chicago, Illinois
Kenneth C. Shestak, MD
Professor
Department of Plastic Surgery
University of Pittsburgh School of Medicine
Chief of Plastic Surgery
Magee Women’s Hospital
Pittsburgh, Pennsylvania
Ali Shirafkan, MD
Resident
Division of Plastic Surgery
Department of Surgery
University of Texas Medical Branch
Galveston, Texas
Robert K. Sigal, MD
Austin-Weston, The Center for Cosmetic Surgery
Reston, Virginia
Kevin H. Small, MD
Director of Plastic Surgery
New York Bariatric Group
New York, New York
Darren M. Smith, MD
Plastic Surgeon
Rapaport Plastic Surgery
New York, New York
Ron B. Somogyi, MD, MSc, FRCSC
Plastic and Reconstructive Surgeon
Assistant Professor
Department of Surgery
University of Toronto
Toronto, Ontario, Canada
David H. Song, MD, MBA, FACS
System Chief
MedStar Health Plastic and Reconstructive Surgery
Professor and Chairman
Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC
Tulsi Roy, MD
Plastic Surgery Resident
Department of Surgery, Section of Plastic and
  Reconstructive Surgery
The University of Chicago Medical Center
Chicago, Illinois
Gustavo A. Rubio, MD
General Surgery Resident
Plastic Surgery Research Fellow
DeWitt Daughtry Family Department of Surgery
University of Miami Miller School of Medicine
Jackson Memorial Hospital
Miami, Florida
Holly S. Ryan, MD
University of Minnesota Medical School
Minneapolis, Minnesota
Christopher J. Salgado, MD
Professor of Surgery
Division of Plastic Surgery
Section Chief
University of Miami Miller School of Medicine
Jackson Memorial Hospital
Miami, Florida
David B. Sarwer, PhD
Associate Dean for Research
College of Public Health and Director of the Center for
  Obesity Research and Education
College of Public Health
Temple University
Philadelphia, Pennsylvania
Christian Schaudy, MD
Department for Maxillofacial Surgery
Evangelisches Krankenhaus Vienna
Vienna, Austria
Luis R. Scheker, MD
Associate Clinical Professor of Plastic and
  Reconstructive Surgery
Department of Surgery
University of Louisville School of Medicine
Louisville, Kentucky
Associate Professor of Surgery of the Hand
Department of Orthopaedics
Universidad Nacional Autonoma De Mexico
Mexico City, Mexico
Joseph M. Serletti, MD
The Henry Royster-William Maul Measey Professor of
  Surgery and Chief
Division of Plastic Surgery
University of Pennsylvania Health System
Philadelphia, Pennsylvania
Contributors

xxvii
Seth R. Thaller, MD, DMD, FACS
Professor and Chief, Program Director
Division of Plastic, Aesthetic, and Reconstructive Surgery
University of Miami Miller School of Medicine
Miami, Florida
Todd A. Theman, MD
Department of Plastic Surgery
The Permanente Medical Group
Santa Clara, California
Dean M. Toriumi, MD, FACS
Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology—Head and Neck Surgery
University of Illinois at Chicago
Chicago, Illinois
Ali Totonchi, MD
Assistant Professor
Medical Director of Craniofacial Deformity Clinic
On-Site Director of Plastic Surgery Residency
Plastic Surgery Division
MetroHealth Medical Center
Cleveland, Ohio
Thomas H. Tung, MD
Professor
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
Barnes-Jewish Hospital
St. Louis, Missouri
Joseph Upton, MD
Professor of Surgery
Harvard Medical School
Children’s Hospital Boston
Beth Israel Deaconess Medical Center
Shriner’s Hospital for Children
Boston, Massachusetts
Herbert Valencia, RN, CFA
Former Surgical Coordinator
Brachial Plexus Program
Miami Children’s Hospital
Miami, Florida
Allen L. Van Beek, BSM, MD, FACS
Adjunct Professor
Department of Surgery
University of Minnesota
North Memorial Medical Center
Minneapolis, Minnesota
Aditya Sood, MD, MBA
Plastic Surgery Resident
Division of Plastic Surgery
Department of Plastic Surgery
Rutgers New Jersey Medical School
Newark, New Jersey
Henry M. Spinelli, MD, FACS
Clinical Professor of Surgery and Neurological Surgery
Department of Surgery and Neurological Surgery
Weill Cornell Medical College
Attending Surgeon
Division of Plastic Surgery
New York–Presbyterian Hospital/Weill Cornell
  Medical College
New York, New York
James M. Stuzin, MD
Clinical Professor of Plastic Surgery
University of Miami Miller School of Medicine
Miami, Florida
Amir Taghinia, MD
Assistant Professor of Surgery
Department of Plastic Surgery
Harvard Medical School
Boston, Massachusetts
Youssef Tahiri, MD, MSc, FACS
Associate Professor
Craniofacial and Pediatric Plastic Surgery
Cedars Sinai Medical Center
Los Angeles, California
Jin Bo Tang, MD
Professor and Chair
Department of Hand Surgery
Chair
The Hand Surgery Research Center
Affiliated Hospital of Nantong University
Nantong, Jiangsu, China
Peter J. Taub, MD, FACS, FAAP
Professor of Surgery, Pediatrics, Dentistry and
  Neurosurgery,
Professor of Medical Education
Division of Plastic and Reconstructive Surgery
Icahn School of Medicine at Mount Sinai
Chief of Pediatric Plastic Surgery
Director of Cleft and Craniofacial Center
Kravis Children’s Hospital
New York, New York
Edward O. Terino, MD, FACS
Medical Director
The Plastic Surgery Institute of Southern California
Agoura Hill, California
Contributors

xxviii
George W. Weston, MD
Austin-Weston Center for Cosmetic Surgery
Reston, Virginia
Jason Wong, MBChB, FHEA, PhD, FRCS(Plast)
Core Surgical Trainee
Department of Plastic and Reconstructive Surgery
University Hospital South Manchester
Manchester, England, United Kingdom
Shannon L. Wong, MD
Assistant Professor
Department of Plastic Surgery
University of Nebraska Medical Center
Omaha, Nebraska
Alan Yan, MD
Former Clinical Fellow
Adult Reconstructive and Aesthetic Craniomaxillofacial
  Surgery
Division of Plastic and Reconstructive Surgery
Massachusetts General Hospital
Boston, Massachusetts
Michael J. Yaremchuk, MD
Chief of Craniofacial Surgery
Division of Plastic and Reconstructive Surgery
Massachusetts General Hospital
Boston, Massachusetts
Peirong Yu, MD, FACS
Professor
Department of Plastic Surgery
MD Anderson Cancer Center
University of Texas
Houston, Texas
James E. Zins, MD, FACS
Chairman
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
Ronald M. Zuker, MD, FRCSC, FACS
Professor of Surgery
The University of Toronto
Staff Surgeon
The Hospital for Sick Children
Toronto, Ontario, Canada
Luis O. Vasconez, MF, FACS
Professor of Surgery (Emeritus)
Department of Surgery
Division of Plastic Surgery
University of Alabama at Birmingham
Birmingham, Alabama
Kurt Vinzenz, MD
Department for Maxillofacial Surgery
Evangelisches Krankenhaus Vienna
Department for Plastic Esthetic and Reconstructive Surgery
Wilhelminenspital Vienna
Vienna, Austria
James E. Vogel, MD, FACS
Associate Professor
Department of Plastic Surgery
The Johns Hopkins Hospital and School of Medicine
2013-2015 American Society for Aesthetic Plastic Surgery
  (ASAPS) Traveling Professor
Past President
John Staige Davis Maryland Society of Plastic Surgeons
Past President
International Society of Hair Restoration Surgeons (ISHRS)
Baltimore, Maryland
Simeon Wall Jr., MD, FACS
Plastic Surgeon, Private Practice
The Wall Center for Plastic Surgery
Jade MediSpa
Shreveport, Louisiana
Assistant Clinical Professor
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
Assistant Clinical Professor
Division of Plastic Surgery
Louisiana State University Health Sciences Center at
  Shreveport
Shreveport, Louisiana
Andreas D. Weber, MD
Surgeon
Orthopedics/Hand Service
Texas Scottish Rite Hospital for Children
Dallas, Texas
Fu Chan Wei, MD, FACS
Distinguished Chair Professor
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taipei, Taiwan
Chang Gung University Medical College
Taoyuan, Taiwan
Contributors

xxix
Video Contents
Video 13.1.
Ischial Pressure Sore Debridement
Linda G. Phillips
Video 14.1.
Wound Preparation and Debridement (Using a low energy ultrasonic device,
SonicOneTM O.R. with SonicVacTM (Misonix))
Aditya Sood, Vasanth S. Kotamarti, and Mark S. Granick
Discussion Video 14.1.
Treatment of Left Ischial Pressure Ulcer
(From Maintenance of Certification in Plastic Surgery MOC-PS- Orgill, DP: Evaluation and
Treatment of Pressure Sores, Plastic and Reconstructive Surgery Journal [In Press, Dec. 2016].)
Discussion Video 16.1.
Injection Technique For RadiesseTM And BellafillTM Using Blunt Injection Cannula To
Volumize Hollow Cheeks
Karol A. Gutowski
Discussion Video 18.1.
Periorbital Phenol - Croton Oil Peel
James E. Zins
Video 20.1.
Endoscopic Brow Lift
Cristiano Boneti and Luis O. Vasconez
Video 21.1.
Facelift Incision Planning
Video 21.2.
Extended SMAS Dissection
Video 21.3.
Neck Lift
James M. Stuzin
Video 22.1.
Preoperative Blepharoplasty Marking
Henry M. Spinelli
Discussion Video 22.1.
Browpexy Technique
Michael P. Ogilvie and Julius W. Few Jr.
Video 23.1.
Two Examples of Narrow Middle Vaults Requiring Spreader Grafts
Video 23.2.
Asymmetric Osteotomies and Subsequent Osteoplasty
Video 23.3.
Dissection of Bilateral Perichondrial Periosteal Flaps on Either Side of Keystone Area
Video 23.4.
Component Separation of Individual Dorsal Elements Followed by Incremental
Reduction of the Septum
Video 23.5.
Use of Power Tools and Piezoelectric Inserts to Precisely Reduce and Model the Dorsal
Bony Cap
Video 23.6.
The Use of Piezoelectric Instrumentation for Osteotomies and Osteoplasty
Video 23.7.
Spreader Grafts and Spreader Flaps Used Individually or in Combination to Configure
Desired Dorsal Aesthetic Lines
Video 23.8.
The Use of an Appropriately Shaped and Perforated Ethmoid Plate to Stabilize a Weak
Septum
Video 23.9.
Two Appropriately Extending Perforated Ethmoid Plate Segments to Straighten and
Stabilize the Septal L-Strut
Video 23.10.
An Excessive Cephalic Trim Weakens the Lateral Crus Losing its Shape and Support
Function
Video 23.11.
Reviewing Configuration of the Same Tip Preoperatively and Postoperatively to
Structural Manipulation Allows Understanding of the Options and Effectiveness of
the Open Approach
Video 23.12.
Careful Excision of SMAS and Underlying Fat to Allow Better Definition in Thick
Skinned Patients
Video 23.13.
A Modified Extracorporeal Septoplasty Implies Leaving a Proximal Stump Of Septum
Just Distal to the Keystone

xxx
Video Contents
Video 23.14.
Secondary Rhinoplasty Often Requires the Reshaping of Bones
Video 23.15.
Diced Cartilage Segments Should be Very Small
Video 23.16.
Rib Cartilage for Extensive Restructuring of Tip and Dorsum
Video 23.17.
Secondary Open Rhinoplasty with Reconstitution Of The Dorsal Plateau By Rib Grafting
Enrico Robotti
Video 25.1.
Avoidance and Treatment of Postoperative Nasal Airway Obstruction
Mark B. Constantian and Mark G. Albert
Video 26.1.
Chin Implant
Video 26.2.
Chin Resuspension
Alan Yan and Michael J. Yaremchuk
Discussion Video 26.1.
Chin Implant
Discussion Video 26.2.
Jaw Angle Implants
Discussion Video 26.3.
Midface Augmentation
Edward O. Terino
Video 27.1.
Perioral Aesthetic Surgery.
Christopher D. Knotts, Byron D. Poindexter, Robert K. Sigal, and George W. Weston
Discussion Video 27.1.
Correction of Alar Base Dystopia by Alar Piriform Pexy
Randal D. Haworth
Video 28.1.
Avoiding Complications in Hair Transplantation
Alfonso Barrera
Video 29.1.
SAFELipo. Fat Separation with “Exploded” Cannula
Video 29.2.
Fat Aspiration with Mercedes Cannula
Video 29.3.
Fat Equalization with Exploded Cannula
Video 29.4.
Improving Contour Deformity with Fat Shifting and Grafting
Simeon Wall, Jr.
Discussion Video 29.1.
VaserTM-Assisted Liposuction
Onelio Garcia, Jr.
Video 30.1.
Abdominoplasty with Circumferential Body Liposuction
Joseph P. Hunstad and Daniel J. Krochmal
Discussion Video 31.1.
Total Body Lift in the Male
Dennis Hurwitz
Video 32.1.
Injection of Fat Using a Cannula
Video 32.2.
Ligament Injection of The Buttocks
Video 32.3.
Surgical Technique: Gluteal Augmentation
Ashkan Ghavami and Joubin S. Gabbay
Video 33.1.
Fat Injection: Labia Majora
Christopher J. Salgado, Lydia A. Fein, Natalie R. Joumblat, and Ajani Nugent
Discussion Video 34.1.
Subpectoral Breast Augmentation
Mitchell Howard Brown
Video 36.1
Marking For A Bilateral Breast Reduction
Seth R. Thaller
Discussion Video 36.1.
Medial Pedicle Vertical Breast Reduction
Elizabeth J. Hall-Findlay
Video 37.1.
Gynecomastia Procedure
Dennis C. Hammond and Kuylhee Kim
Video 38.1
Intraoperative Implant Procedure
Amy S. Colwell

xxxi
Video Contents
Discussion Video 38.1.
Use of TegadermTM Transparent Film Dressing After Reconstruction
Neil A. Fine and Michelle Grim
Discussion Video 39.1.
Superficial Inferior Epigastric Artery Preoperative Flap Markings
David H. Song
Video 40.1.
Premaxillary Setback
Mimis N. Cohen
Video 43.1.
Bilateral Sagittal Split Osteotomy
Video 43.2.
LeFort I Procedure
Video 43.3
Osseous Genioplasty
Pravin K. Patel
Video 46.1.
Home Tissue Expansion
Bruce S. Bauer and Sara R. Dickie
Video 49.1.
Circummandibular Wiring
Seth R. Thaller and David Gerth
Video 50.1.
Prefabrication
Video 50.2.
Orofacial Reconstruction
Kurt Vinzenz and Christian Schaudy
Discussion Video 51.1.
Surgical Voice Reconstruction
Hung Chi Chen
Video 54.1.
Elevation of Latissimus Dorsi Flap with Vascularized Rib
Video 54.2.
Elevation of Latissimus Dorsi Flap with Vascularized Rib and Scapula
Video 54.3.
The Use of Split Calvarial Bone for Cranial Reconstruction
Russell R. Reid
Discussion Video 55.1.
Lower Eyelid Reconstruction
Michael Patipa
Video 56.1
Heavy cheeks – Preoperative and Postoperative
Video 56.2.
Error in Normal Side Nerve Branch Selection – Preoperative and Postoperative
Video 56.3.
Adhesion between the Gracilis muscle and the Dermis. Preoperative and Postoperative
Following Fat injection and Adhesion Release
Video 56.4.
Good Motion and An Unnoticeable Nasolabial Fold – Preoperative and Postoperative
Video 56.5.
Correct Tension for Inserting the Muscle to Expose the Upper Teeth
Video 56.6.
Inability to Elevate the Upper Lip Resulting in Failure Of Upper Lip Muscle-Lip Muscle
Orientation And Fixation
Video 56.7.
Failure To Shorten The Long Oral Orifice in Long Standing Older Patients – Preoperative
And Postoperative
Video 56.8.
Inability to Spontaneously Operate the Muscle And Smile
Video 56.9.
Excessive Contraction Due to Large Recipient Masseter Motor Nerve. Preoperative and
Postoperative Following Nerve Weakening and Muscle Revision
Video 56.10.
Inability to Create Total Symmetry In Bilateral Facial Paralysis – Preoperative and
Postoperative
Video 56.11.
Beneficial “Complication” – Gracilis Muscle Operated by Cross Face Nerve Graft but
Spontaneous Motion Initiated After Procedure
Video 56.12.
Beneficial “Complication” –Gracilis muscle was Supposed to Operate by the Cross Face
Nerve Graft, but Motion Started Unintentially Clinching Teeth
Eyal Gur and Daniel Josef Kedar
Discussion Video 58.1.
Emergent Leg Revascularization
L. Scott Levin
Video 59.1.
DIEP Flap with Vascularized Lymph Node Transfer
Deana Saleh Shenaq and David W. Chang

xxxii
Discussion Video 59.1.
Evolving Beyond the Standard Supermicrosurgery - The “Octopus” Lymphaticovenular
Anastomosis
Wei F. Chen
Video 60.1.
Syndactyly
Andreas D. Weber, Lesley C. Butler, and Scott N. Oishi
Video 62.1.
Cadaver Boutonniere Dissection
Video 62.2.
Acute Open Boutonniere, Lalonde
Video 62.3.
Treatment of Chronic Boutonniere Deformity
Video 62.4.
Chronic Sagittal Band Rupture Reconstruction Using Palmaris Longus Tendon Graft
Video 62.5.
Chronic Sagittal Band Rupture Reconstruction Using Flexor Carpi Radialis
Video 62.6.
Cadaver Dissection for Long Extensor Laceration and Use Of Relative Motion Extension
Splint
Video 62.7.
Intrinsic Release of Swan Neck Deformity
Wyndell H. Merritt
Video 62.8.
Vaughan-Jackson Syndrome
Discussion Video 62.1.
Mallet fractures
Discussion Video 62.2.
Relative Motion Flexion Splinting
Discussion Video 62.3.
Extensor Tendon Repair and Relative Motion Extension Splinting
Donald H. Lalonde
Video 64.1.
Paraumbilical Perforator Flap
David T. Netscher
Video 65.1.
Second Toe Tranfer to the Long Finger for Aesthetic & Functional Reconstruction –
Case Presentation/Standard Markings
Video 65.2.
Second Toe Tranfer to the Long Finger for Aesthetic & Functional Reconstruction –
Recipient Site Preparation
Video 65.3.
Second Toe Tranfer to the Long Finger for Aesthetic & Functional Reconstruction –
Second Toe Flap Harvest and Donor Site Closure
Video 65.4.
Second Toe Tranfer to the Long Finger for Aesthetic & Functional Reconstruction –
Flap Inset and Final Result
Nidal F. AL Deek and Fu-Chan Wei
Video 66.1.
Pearls and Pitfalls: Managing Pain, Patient Selection, Scratch Collapse Test and
Posture-related Upper Extremity Pain
Thomas H. Tung and Susan E. Mackinnon
Discussion Video 66.1.
End to Side Bypass Graft from C5 to Suprascapular Nerve
John A.I. Grossman, Andrew E. Price, Harvey Chim, Herbert Valencia, and Leslie Grossman
Video 68.1.
Pearls & Pitfalls in Collegenase Injection for Dupuytren Contracture
Video 68.2.
Patient Demonstrating Full Extension After A2 Pulley Reconstruction
Nicholas A. Fiore II, David T. Netscher, and Dang T. Pham
Discussion Video 68.1.
Dermal Injection of Local Anesthetic for Needle Aponeurotomy
Discussion Video 68.2.
Dermal Injection of Local Anesthetic for Needle Aponeurotomy
Discussion Video 68.3.
XiaflexTM Injection
Discussion Video 68.4.
Local Anesthteic Injection with XiaflexTM
Discussion Video 68.5.
XiaflexTM Manipulation
Discussion Video 68.6.
Dorsal Local Anesthetic Injection
Discussion Video 68.7.
Palm Lidocaine Injection
Discussion Video 68.8.
Palm Bupivicaine Injection
Discussion Video 68.9.
Manipulation After XiaflexTM Injection
Prosper Benhaim
Video Contents

xxxiii
Video 69.1.
Facial Burns: Case Study
Matthias B. Donelan, Benjamin Levi, Jonathan S. Friedstat, and Charles D. Hwang
Video 70.1.
Hand Graft
Shannon L Wong, Alyson A. Melin, and Debra A. Reilly
Discussion Video 70.1.
Contracture Band Release
Sigrid Blome-Eberwein
Video Contents

(Trang không có chữ)

Introduction
S E C T I O N I

Aphrodite and Pan from the House of the Poseidoniasts of Beirut, Island of Delos Greece.
(National Archaeological Museum, Athens, Greece. ©Hellenic Ministry of Culture
and Sports/Archeological Receipts Fund. Photo: John Patrikianos.)

3

Why We Fail
Robert M. Goldwyn
Men are men, they needs must err.

— Euripides, Hippolytus
CHAPTER
1
The ancients were right: to err is human. No patient and
no surgeon can live a full life without being the victim or
perpetrator of an error. This fact does not condone mistakes
but recognizes their reality. The genesis of human fallibility
has been variously ascribed to Original Sin, divine retribu­
tion, arrested evolution, astral mismatch, capricious fare,
simple chance, malice, and poor judgment. Whatever the
cause or causes, the effect can be the same: despair and
defeat.
After a failure, most of us seek an explanation. Paré’s
philosophy, “I dress and God heals,” may be valid for many
medical situations, but not all. Should God be blamed for a
poorly designed flap? We tend to externalize responsibility:
To look heavenward is easier than to look inward.
Oscar Wilde, however, recognized a basic truth: “There
is a luxury in self-reproach. When we blame ourselves we
feel that no one else has a right to blame us.”
The title of this chapter, “Why We Fail,” was chosen with
care. Originally I called it “Why Things Go Wrong,” but that
would imply that an unfavorable result occurs because we
are helpless victims of circumstances. Responsibility for ac­
tions is the cornerstone of Judeo-Christian religion. The bur­
den on the individual is unrelenting. In our Western cul­
ture, the development of which has been intimately related
to science, it is unacceptable to say only that “something
happened.” We are compelled to probe why it occurred, al­
though the explanation may not be obvious. For example,
if on a wintry day someone falls, the easy answer might be
that it was because of the ice. Indeed, that may be true, but
the real cause might have been that the person was in poor
health or was not wearing proper shoes or was rushing be­
cause he had risen too late from poor planning or laziness.
The purpose of this book is not just to name specific
complications and unfavorable results. The reader should
become aware of the more subtle conditions and factors that
predispose to failure. These situations constitute what might
be called the matrix of mistakes. To improve, the surgeon,
like any other erring human being, must not only recognize
and correct the mistake but, if possible, identify its cause
and avoid it in the future. Admittedly, to be able to do this
requires the talents of a Sherlock Holmes and a Sigmund
Freud. Only by taking an unswerving look at ourselves dur­
ing the course of treating patients can we find the critical
points where errors commonly arise.
Preoperative
Incomplete Initial History and Hasty
Physical Examination
The initial consultation can be either the moment of truth
or the moment of deception. The most common cause of
selecting the wrong patient, making the wrong diagnosis,
or recommending the wrong treatment is not spending
enough time with that patient. An assembly-line approach
in the office invites disaster.
Hazards are inherent in different stages of our profes­
sional life. Success, for example, does not always make for
continued success. On the contrary, it may confer defeat be­
cause of false security. When one begins a practice, one tries
to establish a name. Later, the name by itself may come to
represent the skills and care that the doctor once had but
consciously or unconsciously no longer exercises. The doc­
tor may become sloppy, and the patient is the victim. The

SECTION I INTRODUCTION
4
a patient the result he or she expects, either consciously
or unconsciously, that surgeon should not undertake that
operation.1,2 Selecting the proper patient and giving him
or her the proper operation are the ultimate objectives of
the initial consultation.3 As plastic surgeons, we justifiably
place great reliance on technique, but a well-executed pro­
cedure does not necessarily produce a happy patient. This
is particularly so in aesthetic surgery, where psychological
factors may predominate over anatomic ones.
Certain types of patients should raise the surgeon’s an­
tennae and threshold for operating: those who write an ex­
cessively long letter to arrange the initial consultation, therein
revealing an obsessive and perhaps neurotic nature; those
who are rude or pushy, who want to be treated as an excep­
tion, or who have a high degree of self-entitlement; those
who are unkempt or dirty and therefore may be severely
disturbed and need a psychiatrist rather than a plastic sur­
geon; those who praise you excessively and denigrate your
colleagues; those who give a false history or are indecisive or
vague about what they wish to have done; those who have a
minimal deformity but maximal concern; those who refuse
to conform to the surgeon’s usual regimen in such matters as
undressing or being photographed; those who have shopped
for the “right” plastic surgeon and have come to you as the
fourth or fifth on the list; those who are the compulsive seek­
ers and bearers of multiple operations; those who acquiesce
to have an operation to please someone else, such as a dis­
interested husband or an overbearing parent; those who are
paranoid or visibly depressed; those who are in psychother­
apy without having obtained the approval of their therapist,
without the surgeon having communicated with their thera­
pist, and without the surgeon having obtained the approval
of their therapist; older male patients who seek a rhinoplasty
to resolve sexual inadequacy; “special” patients who are so
important socially that they do not want to be bound by the
usual conventions of medical care; and, finally, patients who
the surgeon simply dislike upon meeting.4
The reality is that surgeons vary in their intuition. How­
ever, in reviewing my own experience and in speaking to
many plastic surgeons who had dissatisfied patients, I have
found that we too often disregarded our presentiments.
When we have more than an inkling that a patient for elec­
tive surgery will be too difficult emotionally for us to man­
age, saying no at the initial consultation is better than invit­
ing the patient back for additional appraisals and bending
over backward, literally contorting our judgment, to give
him or her another opportunity for an operation that should
not be done, at least not by us. Sometimes a member of our
staff will voice uneasiness about a patient because of an in­
cident that should alert us to potential disaster. Ignoring this
information may cause considerable regret later.
Not Seeking a Consultation
Surgeons should periodically objectively assess their own
abilities. If a procedure requires a skill that a surgeon does
not possess, the surgeon should offer a referral or at least
traps and trappings of a flourishing practice replace sound
judgment and hard work. The surgeon may hire someone to
take the history and even to talk to the patient about what
to expect from the procedure and how to pay for it. The
doctor may do the physical examination but in a superficial
manner. Trying to operate on more patients may transform
a physician into a policeman directing the medical traffic in
the office. Under these circumstances, it is not hard to imag­
ine how an error might occur.
No matter how well the surgeon plans the day, often
there is not enough time for an adequate history and physi­
cal examination. It is better to inform the patient of that
fact and to invite him or her back, at no charge, for proper
evaluation. Most patients will appreciate honesty and thor­
oughness and will not mind the inconvenience of having
to make another appointment. Just as the major cause of
automobile accidents is driving at excessive speed for exist­
ing conditions, so the major cause of error in a physician’s
office is seeing too many patients too hastily. Some physi­
cians truly believe that it is their duty to help as many pa­
tients as possible. Others, less nobly motivated, realize that
more patients mean greater income. High aspirations and in­
come are not in themselves objectionable, but too often the
patient becomes the casualty. Perhaps for most physicians,
seeing an excessive number of patients results not from de­
sign but from inadvertence, the inevitable outcome of the
“fit her in somewhere” philosophy. The surgeon and his or
her staff over the years gradually may become stretched be­
yond their capacity.
That most plastic surgeons do aesthetic surgery may pre­
dispose them to regard their procedures as just skin deep.
Because cosmetic patients usually are in good health, the sur­
geon may not believe that a thorough physical examination is
crucial, the assumption being that, whatever the procedure,
the patient will come through unscathed except for local scar­
ring. The surgeon may not inquire about systemic illnesses,
past operations and emotional reactions to them, drug sensi­
tivities, smoking history, and so forth. Furthermore, because
the patient for aesthetic surgery has a focus, such as the nose
or breast, the surgeon may limit his or her attention to one
segment of the patient. In fact, it would be considered odd
and inappropriate if the plastic surgeon did a pelvic exami­
nation on a 40-year-old woman desiring a facelift. However,
in viewing the patient narrowly, the plastic surgeon may for­
get that he or she is a physician with the duty to think of that
individual globally and not only regionally. The patient may
reinforce the plastic surgeon’s superficial approach because
he or she does not want to believe that a rhinoplasty, for ex­
ample, is a real operation with true hazards.
Operating for the Wrong Reasons
The decision to operate should be made for medical or
surgical reasons with regard to the patient and not for the
surgeon’s ambition, convenience, pride, or fiscal needs.
If a surgeon cannot improve a situation, it should be left
alone. If the surgeon believes that he or she cannot give

5
Chapter 1 Why We Fail
Finances
Financial considerations are difficult for both surgeons and
patients to navigate. Certainly medicine involves more than
finances, but when misunderstandings occur in this realm,
the relationship between the patient and the surgeon is
doomed. The payment of a bill by a patient who is unhappy
or dissatisfied is a common impetus for him or her to seek
an attorney. This does not necessarily mean that patients
who sue for malpractice are only those who have been
stressed or distressed by a bill. However, paying someone
for services whose quality is doubtful, either subjectively or
objectively, is disturbing, at the very least. It is imperative
that the financial aspects are clearly stated, understood,
and remembered by the patient and the surgeon before any
procedure is undertaken. Prepayment for the surgery may
solve many but not all of these problems. Prepayment has
the additional advantage of having the patient indicate a
commitment. If he or she feels a conflict about the opera­
tion, it is likely to come to the fore at the time of writing
a check. Should the surgeon detect vacillation, he or she
should welcome this opportunity for learning that a patient
is not a good candidate for the procedure and should tell
the patient to wait until he or she is more certain. I never
charge a patient for an operation that I have not done be­
cause the patient canceled. I do not want to coerce some­
one unwilling to submit to surgery.
Intraoperative
A Poorly Planned or Poorly Performed
Operation
Although bad preoperative and postoperative management
can destroy a good operation, a bad operation can rarely
be transformed into a good one by bedside attentions. This
is true particularly in plastic and reconstructive surgery,
in which the results depend directly although not totally
upon technique.
The operating room should not be the first place a
surgeon performs a procedure. The surgeon should walk
through the surgery mentally within the 12 hours or so be­
fore the operation if the case is elective. Considerations such
as the design of the flap, the type of immobilization, and
the availability of blood and proper equipment should not
be left to happenstance. The ability to improvise may lend a
virtuoso quality to surgical performance, but it should never
replace tactical thinking. A surprising and distressing num­
ber of surgeons do not start thinking about the case until
they take up the knife.
No operation is truly minor. It has been said that a “mi­
nor operation” is what happens to someone else. Every
surgeon and patient should be wary of the “simple case.”
Underestimating a procedure can lead to a surgical “night­
mare.” How apt the Russian proverb: “More drown in the
puddles than in the sea.”
a consultation. Plastic surgeons have criticized other sur­
geons for venturing beyond their competence. They should
not do the same. The era of the omnificent plastic surgeon
has ended. The patient is gravely endangered, as is the sur­
geon, by the undertaking of an unfamiliar procedure. Spe­
cialized plastic surgeons offer a sufficient variety of skills
to make referral not only possible but mandatory. Because
most plastic and reconstructive surgery is elective, the
opportunity to guide the patient to the right physician is
available.
Sometimes a surgeon builds a reputation in a particular
area, such as maxillofacial surgery, but, in truth, with time,
he or she seldom performs those procedures. The surgeon
may be unwilling to relinquish them and to admit to having
a practice that is more “aesthetic” than “traumatic.” He or
she may prefer to retain the self-image of a young prowler
of the emergency room and a “healer,” occasionally per­
forming an operation that preserves this image, but it soon
harms the surgeon’s reputation and, more important, injures
the patient. For many plastic surgeons, there is an inevitable
shift in what they focus on over the years. In my own career,
I performed a considerable amount of hand surgery when I
was first in practice, but this work decreased as other pro­
cedures came to predominate. I recall my discomfort when
I first made the hard decision of referring a patient who
needed a tendon graft to someone who was doing this oper­
ation every week rather than, as in my case, about once every
2 months. A good rule is that a surgeon and patient should
feel comfortable with one another; whenever this rule is
transgressed, error and rancor are more likely to result. I have
yet to meet a patient who has not respected a physician more
for having admitted his or her limitations. Pretending prowess
where none exists is wrong medically, ethically, and legally.
A Poorly Informed Patient
If a patient and his or her family do not understand the
when, why, or what of a procedure, trouble will follow—not
only from the medicolegal standpoint but from the total
therapeutic aspect. A patient may actively dislike an objec­
tively good result if he or she did not comprehend the pain,
time, and cost involved, as well as the nature of the scars and
the limitations of the procedure. Sometimes the patient does
not know what the surgeon has in mind because the surgeon
does not really know. He or she may not have taken the time
to plan the treatment properly. In aesthetic surgery, the fact
that a patient has prepaid and has signed an informed con­
sent does not necessarily mean that he or she has completely
understood and, more important, remembered what the
doctor has said. But even under the best of circumstances,
when the patient is intelligent and the surgeon painstaking
in his or her explanation, verbally, in writing, and perhaps
even with the aid of audiovisual materials, the recall by the
patient is modest. What chance does a patient or surgeon
have under less than ideal circumstances, if the information
is too scanty and too rapidly presented?

SECTION I INTRODUCTION
6
room should not be afraid to speak or to advise when they
see something that could be improved.
Postoperative
Concluding the Case with the
Operation
In reality, the operation is not over until the patient is dis­
charged from the surgeon’s care. The hit-and-run tech­
nique has no place in surgery. The patient and his or her
problems should not fade from the surgeon’s consciousness
as soon as the dressing is applied.
Careful observations, detailed orders, and clear instruc­
tions are critical, especially with the ascendancy of ambula­
tory surgery. If a patient is admitted, the surgeon should be
fully aware of the hospital course and should not abrogate
the responsibility to residents. The surgeon should know,
for example, about unusual pain, vomiting, or other impor­
tant incidents or complaints. The surgeon should be fully
aware of the patient’s medications, blood pressure, pulse,
and temperature. Standards of care should not go down with
the setting sun. If a dressing or splint warrants removal, it
should be done as quickly at night as during the day. The
“wait for the morning” attitude is unacceptable for manag­
ing patients.
Surgeons should take an active part in follow-up and
not assign accountability to others in the office. The sur­
geon must assess how the wound is healing and be avail­
able to listen to the patient’s fears and anxieties. The office
atmosphere must not intimidate a patient into silence. If
a postoperative situation presents problems beyond a sur­
geon’s skills or knowledge, a consultation should be offered
before the patient asks or a tragedy occurs—not just to keep
the surgeon “clean” medicolegally but, more important, to
ensure the patient receives the best treatment.
Surgeons must fight the tendency to become fair-
weather doctors, attentive and helpful when all goes well
but distant and punitive when a complication develops. A
patient who has to bear an unwanted result usually feels iso­
lated and angry, and often guilty. Such a patient should be
encouraged to express his or her sentiments without fear of
reprisal. Unconsciously, the patient might think of his or her
complication as divine retribution for the self-indulgence of
an elective procedure, especially a cosmetic one, that friends
and family considered unnecessary. The physician’s respon­
sibility is to guide the patient through this difficult period
with genuine sympathy. This is certainly not the occasion
for rancor and desultory care (see Chapter 2).
Inadequate Follow-Up
A surgeon who fails to continue to observe his or her pa­
tient for an adequate period will lose a valuable chance to
learn. In contrast, a surgeon who believes in extended ob­
servation will behold many things, sometimes wondrous,
occasionally painful, always instructive. A revised scar that
Subtle factors may ruin a good result. For example, a
surgeon may be stimulated to try something that he or she
ordinarily would not do to impress a new resident or a vis­
iting surgeon. Alternatively, surgeons may not give a par­
ticular operation their full effort because they are battling
the clock—another case, a meeting, patients in the office, a
dinner party at home. The fourth operation on a surgeon’s
schedule should be done with the same high standards as
the first. If the patient is in satisfactory condition, no pro­
cedure should be terminated until it has been executed as
well as possible. Boredom, fatigue, or the press of a schedule
should not compromise judgment or quality. A result that
looks just fair at the end of the operation generally will look
worse in the office. If that final glance discloses a remediable
fault, the surgeon must heed that assessment. A few more
minutes can make a startling difference. Time spent then
is more worthwhile than excuses and explanations later.
Stitches are not sacred: they can and should be removed
and replaced until the desired result is achieved. Michelan­
gelo wisely commented: “Trivials make perfection but per­
fection is not trivial.”
A good surgeon is not necessarily someone whose hands
move fast but someone whose brain keeps ahead of the next
step in the procedure. He or she does not repeat unneces­
sarily.
When I was a resident and rotated onto the anesthesia
service, it soon became apparent to me from the other end
of the table how easy it was to distinguish the excellent sur­
geons from those who were only good or fair. The distinction
was not based on digital dexterity but on planning and judg­
ment. The best do not waste time. Although an operation
should not be a tense affair, it certainly is not a social event.
Those who unnecessarily prolong a procedure are usually
surgeons who have smaller practices and want to savor each
minute or, to be exact, each hour of the session.
Like any professional, a surgeon who is committed to
doing an excellent job must concentrate and avoid distrac­
tions that can result in disaster. Every operation poses the
risk of a suboptimal outcome, complications, and even pa­
tient death.
Surgeons must be attentive to many things and not just
to what they are physically doing. They must be alert to pos­
sible breaks in asepsis; must check all solutions before us­
ing them; must be sure that the patient has been properly
placed on the operating table with all bony prominences
padded; must check that alternating pneumatic boots on
the legs, if used, are functioning even before the patient is
given anesthesia; must communicate with the anesthesiolo­
gist about vital signs. If surgeons have a cavalier approach
to their duties, other surgical personnel will adopt a simi­
lar attitude. Patients trust the surgeons to whom they have
committed themselves. That responsibility deserves the sur­
geon’s best.
Although the surgeon is in charge and must oversee the
activities of many, he or she should do this without becom­
ing a martinet. Creating an uncomfortable and fearful en­
vironment is inimical to success. Others in the operating

7
Chapter 1 Why We Fail
satisfied. However, the unusual and unexpected can occur.
A patient in the hospital may not receive the right medi­
cation or may develop a sensitivity to it; a patient with a
recent rhinoplasty may injure the nose. The scenarios are
infinite. Although the surgeon is not responsible for these
capricious turns of fate, he or she must deal with them ap­
propriately and with equanimity.
Conclusion
The recognition of certain prime factors in failure should
make surgeons less willing to accept an unfavorable result
as an event related only to the patient or emanating only
from chance. In many instances, although not all, its gen­
esis lies with the surgeon, with his or her treatment style.
Although surgeons cannot always assume total responsibil­
ity for an unwanted outcome, they must not delude them­
selves into thinking that they had no part in the occurrence
of any complication. No matter how attentive surgeons are,
fallibility and unpredictability mark the human condition,
and mistakes will occur. Of this sad reality, Hippocrates ob­
served:
Mistakes, no less than benefits, witness to the existence of
the art, for what benefited did so because correctly admin­
istered, and what harmed did so because incorrectly ad­
ministered. Now, where correctness and incorrectness each
have a defined limit, surely there must be an art. For ab­
sence of art I take to be absence of correctness and of incor­
rectness, but where both are present art cannot be absent.

­—The Art, V (W.H.S. Jones,
translator)
Humans are not self-correcting computers. Our capacity
to learn is present but not always used. An error, although
painful and unwanted, nevertheless presents a unique op­
portunity for self-betterment.
initially looked disappointing will have improved miracu­
lously after a year. The reverse also is true. The rhinoplasty
that appeared “just perfect” at 6 months may develop many
imperfections. It is always tempting to quit while ahead—
discharge the facelift patient, for example, after a few
months, when he or she is feeling rejuvenated and grate­
ful. If surgeons truly wish to improve their techniques and
to understand their patients’ reactions to their operations,
however, they should follow them for longer than several
weeks and in many instances, such as after augmentation
mammaplasty, for many years. During this period, the sur­
geon must be genuinely committed to objective evaluation
and resist the temptation to fit the facts to an old thinking
mold. There is a difference between 20 years of experiences
and 20 years of 1-year experiences.
The Iron Man (Woman) Delusion
No surgeon—no human being—is invincible. An operation
is a series of interdigitating sequential acts, whose quality
depends on the soma and psyche of the surgeon as well as
of the patient. An overworked, overstressed surgeon does
himself or herself little good and may do the patient con­
siderable harm. As an athlete must stay in peak shape, it
seems logical for surgeons to try to keep fit physically and
emotionally for their daily performance. Although surgeons
should not shirk their tasks, they must take time to replen­
ish. Periodic vacations or a day enjoying a favorite pastime
are beneficial. A professional life is a marathon, not a sprint.
Chance
No surgeon, even the most careful, skillful, and knowledge­
able, can control every variable in a patient’s treatment. A
passage from Ecclesiastes is pertinent: “. . .time and chance
happeneth to them all.” From that perspective, it is remark­
able that most outcomes are good and most patients are
References
1. Dunofsky M. Psychological characteristics of women who
undergo single and multiple cosmetic surgeries. Ann Plast
Surg 1997;39(3):223–228
2. Wengle H-P. The psychology of cosmetic surgery: old prob­
lems in patient selection seen in a new way—Part II. Ann
Plast Surg 1986;16(6):487–493
3. Goldwyn RM. The Patient and the Plastic Surgeon. 2nd ed.
Boston: Little, Brown and Company; 1991
4. Wengle H-P. The psychology of cosmetic surgery: a critical
overview of the literature 1960-1982—Part I. Ann Plast Surg
1986;16(5):435–443

8

The Dissatisfied Patient
Robert M. Goldwyn
CHAPTER
2
A dissatisfied patient is an unfortunate, stressful reality
that can be prevented only by retiring from practice. Be­
cause this is an impractical alternative, surgeons must seek
more practical and fulfilling ways to manage an unhappy
patient after surgery. Although uncommon, an unsatisfied
patient has an enormous negative emotional impact. It is
thus important to address the management of dissatisfied
patients in a discussion of unfavorable results.1
Background
Physicians seek to help others and to obtain their appro­
bation. It is terribly distressing to have to deal with a per­
son one has not only failed to help, but possibly has made
worse; who, instead of being grateful, is hostile; and who,
instead of applauding the surgeon’s motives and talents,
openly accuses him or her of greed and incompetence and
may actually seek legal redress.
A plastic surgical residency, like most other educational
experiences, does not usually equip surgeons to manage the
unpleasant side of the profession. Residents only address the
results of somebody else’s efforts, and even when they ad­
vance to having their own patients, they are looking forward
to the time when the rotation ends and they can begin their
own practice. However, as practicing professionals, surgeons
are ultimately responsible for results.
Plastic surgeons often practice in high population areas
and are usually unknown to the patient before the initial
consultation, have only brief contact with the patient, and
project an image of wealth. Statistically, most plastic sur­
geons are at the upper end of the socioeconomic ladder and
are portrayed by the media as delighting in displaying their
wealth as well as their talents.
The average patient seeking aesthetic surgery comes
with the belief that perfection is just around the corner.
Some surgeons within the specialty, coupled with the me­
dia, have reinforced this false reality. Although it is true that
most patients will be satisfied and that the surgical results
will be exemplary, this obviously is not true for every patient
and every outcome.
The Patient
As mentioned, some patients arrive with inflated expecta­
tions and unrealistic beliefs of the prowess of the plastic
surgeon. However, many come distrustful of medicine in
general and of any doctor in particular. A few patients are
openly hostile and have the attitude “show me what you
can do.” Unlike when I first began practice, patients today
pointedly ask about the surgeon’s training, experience, ca­
pability, and even previous malpractice suits. The latter in­
formation is available online in many states.
Many patients have been referred by primary physicians
whose incomes are generally less than those of plastic sur­
geons, especially those doing a preponderance of aesthetic
operations. If something does go wrong, the family physician
may not be the most understanding or helpful because of his
or her resentment about the disparity in the financial re­
wards or personal views about aesthetic surgery in general.
Why Is the Patient Dissatisfied?
The first task of the surgeon is to determine why the patient
is unhappy. Typically the patient allows no ambiguity by
voicing a strong, unequivocal statement of the complaint,
but if this is not forthcoming, the surgeon should be alert
to veiled discontent—a sullenness, an irritability, or some
form of passive-aggressive behavior, such as the patient not
keeping appointments or not paying the bill if payment ex­
pectations were not clearly outlined before the operation.

9
Chapter 2 The Dissatisfied Patient
A patient who complains legitimately about an undesir­
able result, for example, infection, asymmetry, or bad scar­
ring, deserves prompt, appropriate attention. A valid com­
plaint merits respect and empathy. A patient who has had
aesthetic surgery may have sought it against the advice of
family, friends, and other physicians and may have paid a
large fee. When something goes wrong, he or she may feel
foolish, ashamed, guilty, and, not unexpectedly, angry. The
patient may believe that this complication is divine recom­
pense for vanity that led him or her to risking his or her
health for something “frivolous” that now has become a dis­
tinct liability.
Mismanaging a Dissatisfied
Patient
The following comments from my patients emphasize the
importance of properly managing dissatisfaction.
“He [another plastic surgeon] always tries to minimize the
problem. He hasn’t really been honest with me. I don’t want
to go back to him even though he said he would do it over
for nothing. I don’t trust him. Suppose he makes a mistake
again. But if I go to someone else, it will cost a lot of money
and I can’t afford it. I already paid him $8,000 and for what
[facelift]?”
“I am bringing my wife here to see you for a second
opinion. It would have helped if Dr. [–] had suggested it. He
never would. His ego could fill a ballroom.”
“He expects me to like him after all I have been
through. He is lucky that I won’t sue him and I really might.
I have trouble enough seeing him for this hole in my face
[concavity after liposuction]. He avoids me like the plague.
Maybe an attorney can get to him.”
“He was there for the money but he is not there for me
now. All I get to talk to is his nurse [secretary]. He really
doesn’t give a damn.”
“If I really thought this would have happened, I
wouldn’t have had it done. Every time I see her, she tries to
talk me into thinking that it [noticeable ectropion] will go
away with time. It has already been 10 months. She won’t
admit that she goofed. I can’t get a word in edgewise with
her.”
“I thought that with your reputation, this wouldn’t
have happened.”
“My boyfriend hasn’t come near me since the opera­
tion. I really can’t blame him. This big hole [skin loss after
abdominoplasty] would disgust me, too.”
Aesthetic patients generally are well informed, often have
sought more than one consultation, and, even though they
have been informed about the possibility of a complication,
have not been prepared emotionally to accept it.
A complication is even harder to accept if the patient
went to a surgeon with a well-known reputation. However,
In some respects, it seems easier to let the patient leave
the office, content to avoid the confrontation. Sooner or
later, however, the unpleasantness will appear and must be
faced. The surgeon must not become so unreceptive that
the patient’s resentment festers and reaches the propor­
tions of a lethal abscess. Before this occurs, a helpful com­
ment might be, “You don’t seem too happy today. What is
troubling you?”
Some patients seem more unhappy than they prove to
be. Once they have expressed their concerns, sometimes af­
ter having been asked, they may respond more positively
than anticipated. This becomes a good foundation on which
to build the ensuing discussion and management. For many
patients, dissatisfaction disappears with reassurance that
circumstances are justified. For example, someone who is
concerned about swelling 2 weeks after blepharoplasty can
be told that the swelling will subside as healing progresses
over the next several weeks or months. A patient may worry
about the bulkiness of a recently turned flap. Here, too, re­
assurance about the progressive flattening will be comfort­
ing, particularly because it is true. Surgeons must keep in
mind that one never reassures a patient if reality dictates
otherwise.
Occasionally, postoperative unhappiness centers on
minimal or nonexistent factors. In this situation, the sur­
geon must determine “why this now?” Is the person de­
pressed and feeling guilty about having an elective operation
or about something else? Has there been a recent loss, such
as a divorce or death? I had a 35-year-old married woman
as a patient who had a very good result after a rhinoplasty
and chin implant but seemed depressed a few weeks later.
She then told me her girlfriend next door had “kept away”
and finally confessed to my patient that she feared rejection
because she thought that my patient, now better looking,
would need her less. Occasionally the culprit in postopera­
tive depression of a mild sort is a primary care physician,
who may have made a comment such as, “You went through
all this to look like that?”—perhaps because the patient did
not consult him or her about the surgery or because of re­
sentment of what the physician considers an excessive fee
for something that is not life-threatening.
Several patients have revealed after aesthetic surgery
that female friends have rejected them because they be­
lieve that the patient is now a threat to them because their
spouse might find the patient more attractive. A more in­
sidious situation is a spouse or lover who may have enjoyed
the personal dominance that resulted from the patient’s
feelings of inferiority about a disliked feature. After surgical
correction, the partner may become less secure about the
leverage he or she formerly possessed. For example, after a
breast reconstruction, a patient left her husband who was
having affairs because he thought that, with her deformity,
she would be lucky to have him and was not in a position
to object to his other activities. One cannot save a marriage
through plastic surgery, but sometimes the procedure may
prompt a divorce.

SECTION I INTRODUCTION
10
Being Distant or Unavailable
The surgeon should not erect a barrier against the patient;
instead the surgeon should be available at all times. An un­
favorable result may actually be an opportunity to deepen
the relationship and sometimes can be converted from a
potentially miserable disaster into a satisfying experience.
Over the years, several of my patients who developed post­
operative problems and were managed with a modicum
of decency actually became enthusiastic supporters and
subsequently referred other patients. Everyone in the of­
fice should be instructed that a patient with an unfavor­
able result has direct and immediate access. I give patients
my personal telephone number to make them feel more
secure. This actually results in fewer telephone calls. If a
surgeon becomes hard to reach, an easy-to-reach attorney
will quickly be on the scene. Medicolegal considerations
aside, it is unfair to the patient for the surgeon to become
unavailable after an operation has been performed, even if
it has not turned out as either the surgeon or the patient
expected. Anyone would certainly resent this attitude if, for
example, a carpenter came to their home, performed a task,
did not produce the expected outcome, and then would not
respond to telephone calls.
Many years ago, a colleague referred a patient from the
West Coast who was going to school in Boston and on whom
he had operated, after which the rotation flap became ne­
crotic in the lower leg. The patient required débridement
and subsequent skin grafting. During the course of her hos­
pitalization, the doctor was in town for a meeting but failed
to see the patient in the hospital. The patient, as well as her
family, knew that he was in town, and although they forgave
him for the complication, they never excused his refusal to
see the patient in follow-up. I was not surprised to learn that
a court battle ensued.
Failing to Structure a Treatment Plan
No patient, especially a dissatisfied one, should be left un­
informed. No matter what the situation, the surgeon can
always structure a plan, even if he or she cannot give specif­
ics. For example, for a patient whose flap has become ne­
crotic, the surgeon can say, “I want to see you in the office
at least twice a week so that I can remove the dead tissue.
How large the wound becomes through this process will
determine whether a skin graft will be necessary. I wish I
could tell you that precisely now, but I cannot. However, I
assure you that you will know everything that I am think­
ing at the time of your visit.”
Precise details are not necessary, but the surgeon should
offer the security that any patient, especially one in distress,
craves. That sense of security would be destroyed if the sur­
geon were to tell the same patient, “I am really not sure what
will happen. I guess I should see you frequently. We can set
up some schedule over the next 2 or 3 weeks. You might
need a skin graft, but you might not. I will let you know
regardless of who the surgeon is or how long he or she has
been in practice, things can go wrong; the mighty also fail
and fall.
Avoiding the Reality
Because most of the results are favorable, surgeons instinc­
tively turn away from an adverse outcome, but the sooner
they accept it, the better they can manage it. I was once
in a colleague’s office when a patient complained of asym­
metry of her nipples after breast reduction. The problem
was obvious to me, but the other plastic surgeon tried to
convince the patient that she was wrong. In my opinion, he
compounded the injury by insulting her intelligence. Most
patients and their friends or family are capable of judging
a scar that is thick (hypertrophic or keloid) or a tip that is
bulbous. Trying to talk the patient out of a problem may
succeed for a few hours, but ultimately it will fail. It will
make the patient angrier and less willing to follow advice. If
there is anything that can drive a patient to another plastic
surgeon or to an attorney, it is distorting reality.
Blaming the Patient or Becoming
Angry at the Patient
To accuse the patient of producing an unfavorable result
usually is unjustified. Although a patient can, by not fol­
lowing instructions (such as smoking after a breast reduc­
tion), cause an adverse result, usually it is the surgeon or
the circumstances of the operation that are to blame. The
surgeon should not then accuse the patient of causing the
poor result. This creates animosity between the patient and
surgeon. Instead the surgeon should recognize the reality
and work together with the patient to correct it.
Not uncommonly, surgeons become angry at patients
when something goes wrong. Although that is understand­
able as an expression of the surgeon’s frustration, it is unac­
ceptable professional behavior.
A plastic surgeon I knew very well used to accuse her
patients of “poor eating habits and nutrition” whenever a
wound healed unsatisfactorily. One patient, whom I saw in
consultation, was incensed by this kind of treatment. She
happened to be an Olympic skier with an excellent diet.
When a patient is angry and the surgeon retaliates in
kind, both regress together. The patient becomes angrier be­
cause he or she becomes more fearful to be in the presence
and hands of a surgeon who has lost control. At the moment
when the patient is looking to the surgeon for guidance and
maturity, it is devastating to have the healer decompensate.
This makes a difficult situation worse.
On a few occasions, I have said to a patient, “I know that
you are angry and I also would be if I were in your position.
However, it is important that we work together. I need your
support, also, to get through this and I can assure you that I
will be there for you.”

11
Chapter 2 The Dissatisfied Patient
People vary greatly in their pain tolerance, and it is impos­
sible to know how much pain another person is having or
should have. Chronic pain after an aesthetic operation usu­
ally signifies a depressed and displeased patient. A busy
plastic surgeon, if not vigilant, may prescribe medication
just to stop the patient’s calls. However, such medication
should be left in the province of an expert such as a psy­
chiatrist or pain specialist.
Those patients who have puzzling persistent pain re­
quiring analgesics and allegedly preventing their return to
work after reconstruction, on the other hand, should lead
the surgeon to suspect malingering for secondary gain emo­
tionally and financially. Depression also is a possibility, and
here again the surgeon should make an effort to enlist a
therapist to determine the dynamics of the behavior and to
offer an effective treatment.
Neglecting the Support System
A dissatisfied patient, like most human beings in difficulty,
needs support. I find it helpful to involve the close and rel­
evant members of the family and friends, even showing
some of them how to change dressings if wound breakdown
has occurred. The referring doctor should be informed to
enlist his or her help.
Most people like to hide an embarrassing situation. Al­
though that is instinctual, it is unwise for surgeons. That
something has gone wrong with an operation mirrors life:
bad things happen. If the surgeon has a secretive way of
dealing with a problem, the patient will sense the shame
of it and will become even more unwilling to deal with the
reality. As the sense of the surgeon’s guilt increases, so does
patient anxiety.
Increasing the Financial Burden
When considering the management of an unfavorable re­
sult, the financial aspects are important. For patients who
had reconstructive surgery, the cost of treating a complica­
tion usually is borne at least in part by insurance. This is
not the case when things go wrong after a cosmetic opera­
tion. In these cases, the patient must pay the entire bill. If
the surgeon has his or her own operating room, the patient
need not be charged for its use. However, many plastic sur­
geons do not have such a facility and depend on the hospi­
tal’s resources. I stipulate in my consent form that a patient
undergoing cosmetic surgery is responsible not only for the
expense of that operation, but also for those associated with
any complication that will involve the hospital. Although I
would not charge a patient for revision after an aesthetic
procedure, I cannot assume the additional expenses of the
hospital. On occasion, the surgeon may sense that another
financial stress for an individual would be unfair and inap­
propriate. Some attorneys advise billing a patient for any
work to relieve a complication because not doing so would
imply guilt. Others contend that not charging the patient
and noting in the record this has been done to lighten the
patient’s financial load is an acceptable alternative in a
when I think that it is necessary, but for now, my secretar­
ies will be in touch with you, and you should keep in touch
with us.”
Failing to Consult
Another aspect of managing a dissatisfied patient is proper
use of a consultant. Most patients want to remain with the
original physician, but it can comfort the patient, as well as
the surgeon, to get another opinion, especially if it is war­
ranted. The surgeon must learn to sense when a patient
wishes a consultation and should not make the patient
jump hurdles to obtain one; however, the patient should
not feel tossed off or shunted, but directed to the other
physician. I usually dictate a letter in the patient’s pres­
ence stating what the problem is and that I would like the
consulting surgeon’s advice, which can be discussed freely
with the patient.
Occasionally, a surgeon may sense that a patient does
not feel that he or she should pay for “the surgeon’s mis­
take.” I believe surgeons should consent to see patients for
colleagues at no charge to maintain the delicate balance be­
tween the unhappy individual and a hard-pressed physician.
However, if the referring physician believes that a patient
should be charged for the consultation, he or she should
inform the consulting surgeon of this and offer to pay for it
personally. Most surgeons likely would not allow a colleague
to do so, but this practice has precedence and does not imply
that the referring surgeon is guilty of any wrongdoing. If the
patient chooses to continue his or her care under another
doctor, either the consultant or someone else, the patient
should not be made to feel guilty. In similar situations, I have
made sure that I knew when the patient was going into the
hospital and have even called the patient in the hospital or
at home afterward. The patient thus realizes that I am truly
interested in his or her well-being, and the doctor who has
cared for the patient also welcomes my support and does not
feel that he or she has lost a professional friend.
Many patients have told me that when they suggested to
another doctor a “second opinion,” the response was hostile.
A recent patient who had loss of skin behind the ear after a
facelift relayed that the surgeon said that he never wanted
to see the patient back if she went to someone else. That
behavior is puerile and irrational, because the patient was a
reasonable individual, justifiably concerned about her face.
Fortunately, time and dressing changes resulted in a satis­
factory outcome.
The patient may require a consultation with a psychia­
trist or a psychotherapist if he or she becomes depressed and
seems unable to handle the stress. This should be suggested
sooner rather than later. Sometimes obtaining agreement
from the patient is difficult. In this situation, the primary
care physician may be helpful.
Ignoring Pain
Some patients reveal their unhappiness by complaining of
pain long beyond the time that would seem appropriate.

SECTION I INTRODUCTION
12
As part of the history, the surgeon should ask the patient
about his or her general health and professional and family
life, just as would be asked if the patient had presented for
the initial procedure. The surgeon should ask the patient
about relationships with the spouse, parents, and employer;
whether the patient is now abnormally depressed; and how
he or she has reacted to previous operations.
When a patient expresses anger at another physician,
the surgeon should not agree with this assessment; instead
the surgeon should tell the patient, “I can understand that
you are angry. I am sure Dr. – is upset also. No good doctor
wants to have an unhappy patient. I can tell you that I wish
all my patients had wonderful results, but that is not true.
Perhaps he is seeing one of my patients as I am seeing you
now.”
The physical examination usually is less of a problem
than the history, because the examination is more objective.
The patient is almost eager to show the scars that “shouldn’t
be there,” the breasts that “don’t match,” the nose that “looks
awful,” the tendon graft that “doesn’t work.” For the consul­
tant, the pitfall is being so absorbed in the local problem that
he or she neglects the patient in totality. A consultant might
fail to notice, for example, how scars have healed from past
operations; or he or she might not detect systemic disease,
such as a malfunctioning thyroid. During the examination,
the surgeon should avoid expressing distress at the results
of previous surgery. The patient will be alert to any sign of
how bad the consultant feels the problem is or how badly
he or she thinks the other surgeon performed.
The patient should be asked to return to the consulting
room for a proper discussion. Most likely the patient feels
the other doctor is not spending enough time with him or
her and would not want another opinion on the fly no mat­
ter how impressive the consultant’s credentials.
This is the most difficult part of the consultation—lit­
erally, “the moment of truth.” I have found it best to give
the patient as honest an appraisal of his or her problem as
is possible, but to do so with warmth and empathy and to
avoid any pejorative statements. I begin simply, “Mrs. –, as
you know, you have had a breast reduction and your prob­
lem is that the scars are more noticeable than you want. It is
true, also, as you said, that the breasts are not symmetrical.
I am sure that for both you and Dr. –, this has been very dis­
tressing, because you both know that he would have wanted
the best for you.” Having structured the problem, the sur­
geon can proceed to the treatment, which, for the patient,
is the most important derivative of the consultation: “Now,
Mrs. –, we would all agree that we have to decide what to do.
Looking backward is not productive and can be very upset­
ting.” The consultant should give a candid but not condemn­
ing evaluation. Patients fear conspiracy among doctors; they
believe that physicians will protect the worst actions of the
most incompetent to maintain the solidarity of their guild.
Unfortunately, in some instances, this is not mere paranoia.
A practical matter must resolved at this point: Who now
is responsible for the patient’s future care? Sometimes the
patient will settle the matter by refusing to return to the for­
trying situation and, rather than implying guilt, denotes
compassion, something a jury might readily understand.
This is a difficult decision, so surgeons facing a revision or
poor result should consult with their malpractice insur­
ance company.
One colleague had a patient whose umbilicus was off-
center after an abdominoplasty. He charged her for its relo­
cation. The patient did not mind paying for the hospital but
was irate that the surgeon made additional money from a
mistake that he made. Again, most people would not toler­
ate that kind of business practice from a carpenter, plumber,
or painter. They are professionals, too, who make mistakes,
but customers expect them to rectify the errors without
added cost.
It is perhaps too simple to say that surgeons should treat
the patient, satisfied or dissatisfied, as they would want to
be treated. In so doing, Emerson’s words should be com­
forting:
Bad times . . .are occasions a good learner would not miss.
When the Dissatisfied Patient Is
Somebody Else’s Patient
A consultant who sees a patient with an unfavorable result
arising from the work of another surgeon is in a singular
position to do considerable good or irrevocable harm. Al­
though in this situation, as in any other medical circum­
stance, the first obligation is the patient, a surgeon also can
help or try to help the other doctor.
The first step is to obtain as objective a history as pos­
sible. Exclamations of disbelief at the patient’s story or the
other surgeon’s behavior should be assiduously avoided. A
patient who is angry and distraught may provide too brief
a history because he or she wishes something done imme­
diately to correct the undesirable result. The patient may
be impatient with the consultant for laboriously trying to
gather the sequence; however, securing a full account is cru­
cial.
I always inform the patient that I wish to get in touch
with the other doctor to improve his or her care. If the pa­
tient does not allow this, I am reluctant to continue treat­
ment.
The following are typical statements from patients
whom I have seen in consultation:
“I went to him because he was supposedly tops in his field.
How could he have done this?”
“He never told me this could happen. I was in and out
of his office 1-2-3.”
In reply to the first statement, I usually am able to truth­
fully say that I have had the same kind of problem or that
this is not an unheard-of difficulty. To the second statement
with its implication that the patient was not properly in­
formed, I have found it beneficial to say nothing and to hear
the other side of the story.

13
Chapter 2 The Dissatisfied Patient
not make the patient feel that he or she has been so de­
formed as to be beyond help. This is a delicate balance to
achieve. Occasionally, nothing further can be done from a
surgical point of view, but the surgeon should be willing
to continue to see the patient and to support him or her
during this difficult period. This is not the time to be cool,
distant, or insensitive.
The consultant should be sufficiently mature not to use
the patient’s misery to denigrate a colleague or to plump his
or her own ego. The golden rule is eminently pertinent here.
Because all who operate are bound to have failures, rejoicing
secretly in someone else’s professional misfortune is imma­
ture and shortsighted.
A consultant who is able to help a patient in trouble
also helps a family and a colleague. Few situations in medi­
cine demand greater sense and sensibility but yield more
satisfaction.
mer doctor. However, frequently the surgeon who arranged
the consultation will continue to care for the patient.
I do not believe it medically wise or ethically correct to
force patients to return to a doctor whom they no longer
trust or like, regardless of whether this attitude is founded.
Plastic surgeons who provide consultations must be willing
to assume responsibility for difficult situations. The fear of
losing respect or trying to avoid a lawsuit should not lead
the consultant to refuse to treat the patient. As a practical
matter, a patient who is refused by a second or third surgeon
is likely to seek redress through an attorney.
At some point in the consultation, the fact should be
reiterated that in surgery, as in all of life, perfection is the
aim but rarely the attainment. Consulting surgeons must
emphasize again that they also have results that are not
excellent and patients who are dissatisfied. In indicating
the limitations of their own talents, however, they must
Reference
1. Goldwyn RM. The Patient and the Plastic Surgeon. 2nd ed.
New York: Little, Brown and Company; 1991

14
Psychological Aspects of Cosmetic Surgery
and Minimally Invasive Treatments
David B. Sarwer and Heather M. Polonsky
CHAPTER
3
The last two decades have witnessed a dramatic increase
in the number of persons who undergo cosmetic surgical
and nonsurgical treatments to enhance their appearance.
Even before this increase, plastic surgeons have long been
interested in the psychological characteristics of individu­
als who choose to undergo these procedures as well as the
psychological changes surgeons commonly observe postop­
eratively. The earliest reports in this literature from decades
ago characterized most persons seeking surgery as suffering
from mood or anxiety disorders, schizophrenia, or person­
ality disorders. These early reports, however, have not been
confirmed by more contemporary research studies nor clin­
ical impressions of plastic surgeons. More recent investiga­
tions of patients have focused on psychopathology, but also
motivations for surgery. Body image dissatisfaction is be­
lieved to be one of the strongest motivations for surgery. For
some patients, however, this dissatisfaction may be extreme
and suggestive of the presence of body dysmorphic disorder
or other forms of psychopathology. These conditions are
likely of greatest relevance to plastic surgeons because of
their likely association with poor postoperative outcomes.
They are also the conditions in which plastic surgeons will
most commonly ask patients to undergo a consultation with
a mental health professional before surgery.
This chapter begins with an overview of the literature
on psychological aspects of cosmetic surgery, including a
discussion of the sociocultural factors that have contrib­
uted to the popularity of cosmetic surgery, as well as the
psychological factors that motivate individual patients. The
psychiatric conditions most commonly seen in cosmetic sur­
gery patients are also detailed. The research in these areas
is used to provide recommendations on the psychological
assessment of new patients who present for cosmetic medi­
cal treatments.
The Popularity of Cosmetic
Surgery
Over the past 2 decades, cosmetic surgical and minimally
invasive treatments have exploded in popularity. There
likely are a number of potential explanations for the dra­
matic increase1–4:
•• Technologic advances have made many of the surgical
treatments safer.
•• More general advances in medicine have decreased the
length of most postoperative recovery periods.
•• Minimally invasive treatments have even less associated
risk and recovery time, as well as lower relative cost,
both of which fuel their appeal to patients.
•• Cosmetic procedures, unlike other forms of medicine,
readily lend themselves to direct-to-consumer
advertisements in a variety of outlets such as city
and regional magazines, billboards, and bus stop
advertisements. Their banner advertisements on
websites and other forms of mass media, as well as the
entertainment industry, have all contributed to the
growth of cosmetic surgery.
•• Cosmetic surgery has long been a very popular topic
for women’s (and men’s) beauty magazines, which
often tout the latest advances in the field, and the
last decade has witnessed unprecedented coverage of
cosmetic surgery on television—from informative health
programs to reality-based patient contests, as well as
surgeon-focused shows.
•• A growing number of celebrities now publically reveal
their experiences with cosmetic surgery, something not
seen in Hollywood decades ago.