Plastic Surgery Volume 1 Principles 4th

15
The 19th century
Fig. 2.10  Nasal reconstruction with the arm flap. (A) Preoperative view of the patient. The missing nose and flap are outlined. (B) The flap sutured into position. (C) Final
result. (Reproduced from Tagliacozzi G. De Curtorum Chirurgia per Insitionem. Venice: Bindoni; 1597.)
B
C
A
reported in 17th- or 18th-century literature. Instead of recom­
mending autologous tissue for restoring a missing nose, sur­
geons like Fallopio (1523–1562), Heister (1683–1758), Camper
(1722–1789), and others advocated the application of a pros­
thesis, convinced that noses made out of wood or silver were
far superior to those of skin.
The rebirth of plastic surgery
The 1794 letter to the editor of the Gentleman’s Magazine (see
above) holds a key position in the revival of plastic surgery.
The English surgeon Joseph Constantine Carpue (1764–1846)
read it and made practical and successful use of its contents.
In 1814, he carried out the first forehead flap rhinoplasty of
modern time at St. Bartholomew’s Hospital, London, on an
officer of His Majesty’s Army, who had his nose amputated
during a battle. The operation lasted 35 minutes, “it was no
child’s play, extremely painful – the officer said – but it was
no use complaining.” At the end he exclaimed: “my God,
there is a nose!”
In 1816, Carpue issued an account of nasal reconstruction,
which marks the prelude to the rebirth of modern plastic
surgery (Fig. 2.11).21
The 19th century
The golden age of plastic surgery
Carpue’s work was immediately translated into German, and
Carl Ferdinand von Gräfe (1787–1840), Professor of Surgery
at Berlin University, promptly initiated the operation. In 1818,
he published Rhinoplastik oder die Kunst den Verlust der Nase
organisch zu ersetzen (Rhinoplasty: or the Art of Reconstructing
the Nose), where he compared the Italian and Indian proce­
dures.22 Von Gräfe supported the arm flap, as he was unhappy
about forehead donor site scar morbidity.
The publications of Carpue and von Gräfe stimulated the
interest of European surgeons to carry out nasal and other
reconstructions. In Germany, Johann F. Dieffenbach (1794–
1847), head of surgery at La Charité Hospital in Berlin, per­
formed rhinoplasty, facial restorations, cleft lip and palate
repairs. He reported his contributions in Chirurgische Ehrfah­
rungen (Surgical Experiences), issued in 1829.23 In France,
Jacques Mathieu Delpech (1777–1832), chief surgeon at Mont­
pellier, wrote Chirurgie Clinique de Montpellier in 1828, with a
detailed section on rhinoplasty.24 Outstanding works on the
rediscovered art were presented by Pancoast (1805–1882)25 in
the US, Balassa (1814–1868)26 in Hungary, and Sabattini
(1810–1864)27 in Italy. A review of the state of the art of nasal
reconstruction in Europe in the mid 19th century was pub­
lished by Nélaton and Ombrédanne in 1904,28 and more
recently by McDowell,29 Rogers,30 and Mazzola.31
With the advent of anesthesia (1846) and the possibility of
closing the donor site primarily, leaving a scar that was often
unnoticeable, forehead rhinoplasty became the procedure of
choice due to its simplicity, good color match, and excellent
results.
The first attempt to close a cleft palate goes back to the
second decade of the 19th century. The priority is shared
between Carl Ferdinand von Gräfe32 and Philibert Roux
(1780–1854) from France.33 However, the greatest advance was
made in 1862 by Bernard von Langenbeck (1810–1887), who
outlined two mucoperichondrial flaps obtaining a more reli­
able closure.34 Refinements in cleft lip repair were published

16
CHAPTER 2 • History of reconstructive and aesthetic surgery
by the Frenchmen Joseph Malgaigne (1806–1865)35 and Ger­
manicus Mirault (1796–1879) in 1844.36
Reconstructive procedures for lip37 were reported by Pietro
Sabattini in 1838, using the lip switch technique27,38 (Fig. 2.12),
and by Victor von Bruns (1812–1883) in 1857, using double
lateral flaps for oral sphincter restoration39 (Fig. 2.13), whereas
eyelid repair was reported by Johann Fricke (1790–1841) in
1829, who described a pedicled skin flap from the ipsilateral
temple or cheek region to correct upper or lower eyelid
defects, respectively40 (Fig. 2.14).
One of the greatest advances in 19th-century surgery was
the demonstration that a piece of skin, fully separated from
its original site, might survive when transplanted to another
part of the body to cover a granulating raw surface.41 This
Fig. 2.12  The lip switch technique for upper
lip repair. (A) Flap outlining. (B) Final result.
(Reproduced from Sabattini P. Cenno storico
dell’origine e progressi della Rinoplastica e
Cheiloplastica seguita dalla descrizione di
queste operazioni praticamente eseguite sopra
un solo individuo. Bologna: Belle Arti; 1838.)
A
B
Fig. 2.11  Nasal reconstruction with
the forehead flap. (A) Preoperative view.
(B) The flap transposed into position.
(Reproduced from Carpue JC. An Account
of Two Successful Operations for Restoring
a Lost Nose from the Integuments of the
Forehead, in the Case of Two Officers of his
Majesty’s Army. London: Longman, Hurst;
1816.)
A
B
became possible through the pioneering work of Giuseppe
Baronio (1758–1811) from Milan, who performed the first
autologous skin graft in a ram in 1804 (Fig. 2.15).42,43 Sixty-
five years later, Jacques Reverdin (1842–1929) carried out the
first successful epidermic graft on a human being at Hôpital
Necker in Paris, opening a new era in wound-healing man­
agement.44 The route for skin grafting was traced. A few
years later, Louis Ollier (1830–1900) transferred a large piece
of split-thickness skin, which included the superficial layers
and underlying dermis.45 Carl Thiersch (1822–1895)46 and
John R Wolfe (1824–1904)47 made further advances in the
procedure. In the late 1800s, skin grafting became the pre­
ferred solution for the management of chronic and granulat­
ing wounds.

17
The 20th century
Fig. 2.13  (A,B) The double lateral flaps for lower lip repair. (Reproduced from von
Bruns V. Chirurgischer Atlas. Tübingen: Laupp; 1857.)
A
B
Fig. 2.14  (A–D) Upper and lower eyelid repair with a temporal and cheek flap, respectively, according to Fricke. (Reproduced from Fritze HE, Reich OFG. Die plastische
Chirurgie. Berlin: Hirschwald; 1845.)
A
B
C
D
Fig. 2.15  First autologous skin graft in a ram. (Reproduced from Baronio G. Degli
innesti Animali. Milan: Stamperia del Genio; 1804.)
The 20th century
The origin of modern plastic surgery
Trenches played an important role during World War I.
Created for shielding purposes, they actually only protected
soldiers’ lower body and trunk, whereas the head and neck
remained exposed to enemy weapons. As they returned home,
soldiers with major maxillofacial mutilations found it impos­
sible to step back into society, and this constituted a new social
problem. Treatment of these devastating facial wounds urged
the development of a new discipline, reconstructive surgery.
The first plastic surgeons came from general surgery, otolar­
yngology, or orthopedics during the first two decades of the
20th century.
Associations were created all over the world to help these
poor individuals. The most famous was Les gueules cassées
(The Facial Cripples), founded in France in 1921, by Colonel
Picot. In addition to these associations, France, the UK,
Germany, Italy, and Czechoslovakia established specialized
centers to manage injuries that had never been seen before.
The key to success was the cooperation between plastic sur­
geons, trained in soft-tissue defect management, and oral
surgeons, expert in stabilizing bone fractures using dental
appliances.

18
CHAPTER 2 • History of reconstructive and aesthetic surgery
Fig. 2.16  Dramatic facial mutilations from World War I. (Reproduced from Pickerill
HP. Facial Surgery. Edinburgh: Livingstone; 1924.)
Fig. 2.17  Sequelae of facial burn from World War I. Repair using the tubed flap. (A) Preoperative view of the patient. (B) Outlining of the tubed flap. (C) The flap in
position. (D) Final result. (Reproduced from Gillies H. Plastic Surgery of the Face. London: Frowde, Hodder and Stoughton; 1920.)
A
B
C
D
Hippolyte Morestin (1868–1919), who worked with the
dentist Charles Auguste Valadier (1873–1931) at Hôpital Val-
de-Grâce (Paris), first realized the importance of such a team
approach. For this he is considered the pioneer in facial
reconstructive surgery.
In 1915, the New Zealand otolaryngologist Harold Gillies
(1882–1960), at that time working in France on behalf of the
Red Cross, visited Val-de-Grâce military hospital. He was
much impressed by the work of Hippolyte Morestin and
Valadier pushed him to take care of facial disfigurements. In
1917, upon his return to the UK, Gillies established a center
for the management of face and jaw injuries at Queen’s Hos­
pital, Sidcup. It became the referral center in Europe. Treat­
ment was provided to British and allied soldiers wounded in
the Battle of the Somme (July 1, 1916), where Britain suffered
almost 500 000 casualties with an enormous number of dra­
matic facial mutilations (Fig. 2.16). Gillies operated among a
multidisciplinary team with William Fry (1889–1963) and
Henry Pickerill (1879–1956) as dental surgeons, and a quali­
fied group of anesthesiologists. He systematized new recon­
structive procedures, like the tubed flap, described by the
Russian Vladimir Filatov (1875–1956),48 which allowed the
coverage of large skin defects, but also skin flaps, bone, carti­
lage, and skin grafts (Fig. 2.17). Gillies reported his experi­
ences in Plastic Surgery of the Face, issued in 1920.49
In Germany Erich Lexer (1867–1937), one of the founders
of maxillofacial surgery, built up a vast experience on the
repair of the face, mandible, and eye socket using cartilage,
bone, skin, and fat graft. He published a book on reconstruc­
tive surgery in 1920.50
The Dutch surgeon Johannes Esser (1877–1946) was active
at Tempelhof Hospital, Berlin, and in Vienna. Between 1916
and 1918 Esser codified some of the flaps currently used
today: cheek rotation51 (Fig. 2.18), bilobed, island, and arterial­
ized flaps, which he called biological flaps.52 In Italy, Gustavo
Sanvenero Rosselli (1897–1974) was appointed head of the
Padiglione per i Mutilati del Viso (Pavilion for Facial Cripples)
in Milan (Fig. 2.19). It became a European referral center for
reconstructive surgery and was visited by surgeons from all
over the world.
Frantisek Burian (1881–1965) headed an important plastic
surgery unit in Prague, Czechoslovakia.
In the US the specialty only grew after World War I. Vilray
Blair (1871–1955), trained at Sidcup, established the first
independent unit in the US for the care of complex maxillo­
facial injuries at Walter Reed Hospital. Other renowned
reconstructive surgeons were Robert Ivy, Truman Brophy,
John Staige Davis, and the Armenian Varaztad Kazanjian.

19
The 20th century
Fig. 2.18  Cheek flap transposition for closing
of an orbitopalpebral defect. (Reproduced from
Esser JFS. Die Rotation der Wange. Leipzig:
Vogel; 1918.)
A
B
The training programs
By the end of World War I, reconstructive techniques had
achieved surprising results. Transfer of skin flaps (tubed or
pedicled) and use of grafts (skin, cartilage, bone, fat) became
routine procedures. New units were established all over the
world. Thus, the need for training programs, where young
doctors could become familiar with reparative methods,
was essential. Queen’s Hospital at Sidcup, headed by Sir
Harold Gillies, was probably the most famous for the manage­
ment of facial injuries. Anesthesia improved considerably
thanks to Ivan Magill, who developed nasal and endotracheal
intubation. Other training programs in the UK were organized
by Sir Archibald McIndoe, Rainsford Mowlem, and Pomfret
Kilner.
In Paris, the otorhinolaryngologist Fernand Lemaître
(1880–1958) established a residency at the International Clinic
of Oto-Rhino-Laryngology and Facio-Maxillary Surgery,
having Eastman Sheehan (1885–1951), Professor of Plastic
Surgery at Columbia University New York, as course director
Fig. 2.19  The Pavilion for Facial Cripples in Milan, headed by G. Sanvenero
Rosselli (1897–1974).
Fig. 2.20  Fernand Lemaître and Eastman Sheehan at the International Clinic in
Paris, in 1927.
(Fig. 2.20). The 2-year fellowship included an intense program
of lectures and practical surgical demonstrations. Attendees
from various parts of Europe and the US were numerous.
Among them was the Italian Gustavo Sanvenero Rosselli,
later appointed head of the Plastic Surgery Clinic in Milan. In
the US the first training program was organized by Vilray
Blair at Washington University in St. Louis.
The birth of the scientific societies
The aim of the scientific societies was to improve the scientific
level of the specialty and to defend the public from charlatans.
The first society was the American Association of Oral and
Plastic Surgeons, established in 1921 by Truman Brophy
(1848–1928), who strongly supported close cooperation
between oral and plastic surgeons. Initially membership
required the MD and DDS degrees.
In Europe, the first society was the Société Française de
Chirurgie Réparatrice Plastique et Esthétique, established in
1930 by Charles Claoué (1897–1957) from Bordeaux and Louis
Dartigues (1869–1940) from Paris. It only lasted 2 years.

20
CHAPTER 2 • History of reconstructive and aesthetic surgery
In 1931, Jacques Maliniak (1889–1976) founded the Ameri­
can Society of Plastic Surgeons.
The first supranational society was the Société Européenne
de Chirurgie Structive, created in 1936 by the Belgian Maurice
Coelst (1894–1963) (Fig. 2.21), with the aim of gathering annu­
ally all those international specialists interested in the new
discipline.53 The term structive was coined by Johannes Esser,
as he considered it more appropriate than “plastic” to empha­
size the repairing concept.
In 1937, Vilray Blair organized the American Board to
certify real plastic surgeons.
The scientific journals
At the time of the foundation of the American Society (1931),
the Belgian Maurice Coelst established and edited the Revue
de Chirurgie Plastique (Fig. 2.22). The journal, the first one on
this topic, played an important role in the history of plastic
surgery between the two wars. Thanks to an international
editorial board, which included the most prestigious plastic
surgeons, the journal published high-quality papers written
by Gillies, Maliniak, and Rethi, the proceedings of the Ameri­
can Society of Plastic Surgery and those of the Société Française
de Chirurgie Réparatrice Plastique et Esthétique.54 Papers
appeared in the author’s preferred language and were sum­
marized in English, French, and German.
In 1935, the Revue de Chirurgie Plastique changed its name
into Revue de Chirurgie Structive, becoming the official journal
of the Société Européenne de Chirurgie Structive. The Revue
lasted until the end of 1938 (8 years), when it ceased publica­
tion, due to the advent of World War II.
In 1946, the Plastic and Reconstructive Surgery Journal was
established and Warren B. Davis was appointed as an editor.
The bases for the official recognition of plastic surgery as
an independent specialty were settled.
Postwar plastic surgery
Recent history sees an incredible development of new recon­
structive procedures, initiated in the 1960s with the recogni­
tion of arterialized flaps, continuing with the clinical definition
of the cutaneous vascular territories nourished by a single
vessel, first identified by Carl Manchot (1866–1932) in 188955
(Fig. 2.23), and culminating with their microvascular transfer.
Fig. 2.21  Executive Council members of the Société Européenne de Chirurgie
Structive, Brussels, 1936. From left to right: Sir H. Gillies, J. F. S. Esser, M. Coelst,
P. Kilner, G. Sanvenero Rosselli.
Fig. 2.22  The first issue of the Revue de Chirurgie Plastique, established by M.
Coelst in 1931.
The application in surgical practice of musculocutaneous
flaps, originally described by the Italian Iginio Tansini
(1855–1943)56 (Fig. 2.24), the introduction of craniofacial tech­
niques, developed in the late 1960s by Paul Tessier (1917–
2008),57 the systematization of breast reconstruction, the use
of fat grafting for numerous aesthetic and reconstructive
indications,58 and even the most recent face transplantation,
constitute further achievements of our specialty.
Aesthetic surgery
The origin
The history of aesthetic surgery begins in 1845, when Johann
F. Dieffenbach (1794–1847) described external incisions to
reduce large, hanging noses with the dual purpose of modify­
ing the nasolabial angle and decreasing the size of the nose.59
No illustration was provided. The same operation was
undertaken a few years later by the Latvian surgeon Julius
von Szymanowski (1829–1868), who reported it in his
“Operatzij poverchnosti…” (Handbook of Operative Surgery),60
showing the illustration of the procedure. The change of the
nasolabial angle and the aesthetic goal of the procedure were
emphasized.
Correction of prominent ears, performed in 1881 by the
New York surgeon Edward Ely (1850–1885) and modifications
of nasal appearance are considered among the first purely
cosmetic procedures.61

21
Aesthetic surgery
Fig. 2.23  The cutaneous vascular territories nourished by a single vessel.
(Reproduced from Manchot C. Die Hautarterien des menschlichen Körpers. Leipzig:
Vogel; 1889.)
Fig. 2.24  The latissimus dorsi musculocutaneous flap according to Tansini. (A) Flap outlined. (B) Flap transposition. (C) Final result. (Reproduced from Tansini I. Sopra il
mio nuovo processo di amputazione della mammella. Gazz Med It 1906;57:141.)
A
B
C
In 1887, John Orlando Roe (1848–1915), an otolaryngologist
from Rochester, showed members of the New York Medical
Society that reduction of a bulbous or “pug nose,” as he
named it, under local anesthesia and on outpatient basis, was
feasible.62 Four years later, he presented hump removal using
scissors at the same society.63 The following year, Robert Weir
(1838–1927), a general surgeon from New York, described alar
base excision, now eponymously named “Weir operation”, to
lower an overprojected nose.64
On the other side of the ocean, in Europe, aesthetic rhino­
plasty started in Berlin, in about the same period, with Jacques
Joseph (1865–1934), who codified the steps of the technique
in a rigorous sequence, still used today after almost 100 years,
with minimal variations (Fig. 2.25). For at least 20 years,
Fig. 2.25  Jacques Joseph (1865–1934), carving a piece of ivory, before inserting
it into the nasal dorsum. (Reproduced from Joseph J. Nasenplastik und sonstige
Gesichtsplastik nebst einem Anhang über Mammaplastik. Leipzig: Kabitzsch; 1931.)

22
CHAPTER 2 • History of reconstructive and aesthetic surgery
regarded Sheehan as a publicity-seeking skilled operator.
Maliniak is best remembered as the founding member of the
American Society of Plastic Surgeons in 1931. He was a prolific
writer; Sculpture in the Living (1934)69 and Rhinoplasty and
Restoration of Facial Contour (1947)70 are some examples. He
had an important aesthetic surgical practice in New York,
mainly for nose and breast. Webster was one of the founding
fathers of US plastic surgery and a talented surgeon in the
reconstructive as well as aesthetic fields. Smith, like Sheehan,
was course director at Lemaître’s International Clinic in
Paris, and author of Reconstructive Surgery of the Head and
Neck, issued in 1928 with a section devoted to aesthetic
rhinoplasty.71
In Paris, Suzanne Noël (1878–1954), active feminist and
founder of the Soroptimist Club of Europe, established a suc­
cessful solo practice in the very exclusive 16th arrondissement.
Her operations were simple but effective, mainly related to
facial rejuvenation and entirely performed on an outpatient
basis (Fig. 2.26). Major surgery, such as abdominoplasty or
mammoplasty, was executed in a private clinic. In 1926, she
published La Chirurgie Esthétique. Son Rôle Sociale, one of the
first textbooks on this topic and the first written by a woman.72
In 1928 she was awarded the Legion of Honour. Raymond
Passot (1886–1933), a leading Parisian aesthetic surgeon,
added innovative techniques for breast ptosis, abdomen and
facial rejuvenation. His book La Chirurgie Esthétique Pure,
dating from 1931, showed a wide range of operations in the
field of aesthetic surgery73 (Fig. 2.27). Julien Bourguet (1876–
1952), another Parisian cosmetic surgeon, became renowned
for having first presented the transconjunctival approach for
baggy eyelid correction in 1929.74
Joseph managed the aesthetic rhinoplasty scenario in Europe,
receiving the most famous patients from every part of the
world. His experience was included in a monumental work,
Nasenplastik und sonstige Gesichtsplastik (Rhinoplasty and other
Facialplasties), published in 1931, which remained an unsur­
passed text for several decades.65
The development
The problem of the beauty doctors
The real explosion of aesthetic surgery took place in Europe
and in the US between the two world wars.
The importance given to personal appearance produced, in
the early 20th century and especially during the interwar
period, a horde of quacks, charlatans, and beauty doctors
often working in beauty salons, exclusively on a commercial
basis. They advertised in newspapers, women’s magazines,
and yellow pages as cosmetic surgeons. They appealed to
popular naivety by promising a more attractive look with
simple, fast procedures on an outpatient basis, at relatively
high cost and by insisting on how beautiful faces and noses
were crucial in creating a favorable first impression for finding
a job, or expanding social relationships.66
To establish a barrier against beauty doctors and in an
attempt to isolate them, true plastic surgeons, practicing
reconstructive as well as aesthetic procedures, founded plastic
surgical societies (see above). However, it was not an easy task
because the general public was more interested in the achieve­
ments of cosmetic surgery than in the outcome of reconstruc­
tive procedures.
An example is given by Charles C. Miller (1880–1950),
regarded as an “unscrupulous charlatan” by some or “the
father of modern cosmetic surgery” by others for having
published in 1907 The Correction of Featural Imperfections, a
pioneering work on aesthetic procedures, where facial opera­
tions, such as double-chin excision, eyelid and nasolabial fold
modification, were illustrated.67 Miller made extensive use of
paraffin injections, considered the ideal filler for improving
saddle nose and cutaneous depressions. When paraffin was
abandoned because of devastating local and systemic sequelae
(paraffinomas, pulmonary embolism, phlebitis), he replaced
it with crude rubber mixed with gutta-percha and ground in
a mill.68
Another borderline cosmetic surgeon was Henry J. Schire­
son (1881–1949), who knew a moment of fame in the US for
having successfully operated on a British actress. Apart from
this episode, he faced a series of lawsuits for malpractice
which culminated in having his license revoked for a period
of time. In 1944, Time defined him as the “king of quacks”.
Trained surgeons made considerable efforts to establish a
positive view of plastic surgery. Their talent contributed to the
transformation of a field regarded with suspicion into an
accepted branch of surgery. Eastman Sheehan (1885–1951),
Jacques Maliniak (1889–1976), Jerome P. Webster (1888–1974),
Vilray Blair (1871–1955), Ferris Smith (1884–1957), and others
all played important roles in creating plastic surgery’s profes­
sional and public image during the years the specialty was
taking shape. Sheehan, course director at Lemaître’s Interna­
tional Clinic in Paris (Fig. 2.20), was elected President of the
American Association of Plastic Surgeons in 1935, despite the
controversial view of him by many American colleagues, who
Fig. 2.26  Result of a facelift carried out by Suzanne Noël (1878–1954) about
1925. (Reproduced from Noël S. La Chirurgie Esthétique. Son rôle Sociale. Paris:
Masson, 1926.)
A
B

23
Aesthetic surgery
In Berlin, Jacques Joseph carried out a wide variety of
cosmetic operations from rhinoplasty to reduction of promi­
nent ears, facelifting and reduction mammoplasty.65 Eugen
Holländer (1867–1932) is credited with being the first one who
reported on a facelifting. “Victim myself of the art of feminine
persuasion, a few years ago, I performed the excision of a
piece of skin along the hairline and the natural folds of the
ageing wrinkles and I rejuvenated the drooping cheek for the
satisfaction of the beholder”.75 In a later publication he
affirmed that this occurred in 1901 and that the patient was a
Polish aristocrat.
In the same paper, Holländer showed two cases of facial
atrophy treated by him with fat injection, and this was the
first account reported in the literature.
Postwar aesthetic surgery
After World War II and in more recent years, aesthetic surgery
grew significantly. The number of plastic surgeons around the
world increased and the specialty expanded. Techniques for
the correction of noses, faces, necks, eyelids, ears, chins,
breasts, and abdomens improved considerably. New opera­
tions for solving a myriad of cosmetic problems developed. A
typical example is management of the hypoplastic breast.
Over the years it was treated with paraffin, sponge implants,
fat grafts, and liquid silicone, with poor or unpleasant results.
In the mid-1960s the silicone mammary prosthesis appeared
on the market, representing the first convincing solution.
Liposuction, introduced in the mid-1980s, soon became one
of the most popular procedures. Faceliftings, fillers, botulinum
toxin, and fat injection favorably improved the demand for
facial rejuvenation.
Fig. 2.27  The cover of the book on aesthetic surgery by Raymond Passot
(1886–1933), published in 1931.
2. Majno G. The Healing Hand. Man and Wound in the Ancient World.
Cambridge: Harvard University Press; 1982.
5. Ballantyne JW. The teratological records of Chaldea. Teratologia.
1894;1:127–142.
18. Gnudi MT, Webster JP. The Life and Time of Gaspare Tagliacozzi. New
York: Reichner; 1950.
30. Rogers BO. Nasal reconstruction 150 years ago: aesthetic and other
problems. Aesth Plast Surg. 1981;5:283–327.
31. Mazzola RF. Reconstruction of the nose. A historical review.
Handchir Mikrochir Plast Chir. 2007;39:181–188.
57. Tessier P, Guiot G, Rougerie J, et al. Ostéotomies cranio-naso-orbito-
faciales. Hypertélorisme Ann Chir Plast. 1912;669–712.
61. Rogers BO. A chronologic history of cosmetic surgery. Bull NY
Acad Med. 1971;47:265–302.
66. Haiken E. Venus Envy. A History of Cosmetic Surgery. Baltimore:
Hopkins University Press; 1997.
69. Maliniak JW. Sculpture in the Living. New York: Pierson; 1934.
70. Maliniak JW. Rhinoplasty and Restoration of Facial Contour.
Philadelphia: Davis; 1947.
71. Smith F. Reconstructive Surgery of the Head and Neck. New York:
Nelson; 1928.
74. Bourguet J. Notre traitement chirurgical de «poches» sous les yeux
sans cicatrice. Arch Fr Belg Chir. 1928;31:133–136.
Access the complete reference list online at

23.e1
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11. Celsus AC. De Medicina, Libri VIII. Florence: Nicolaus Laurentius;
1478.
12. Lascaratos J, Cohen M, Voros D. Plastic surgery of the face in
Byzantium in the fourth century. Plast Reconstr Surg.
1998;102:1274–1280.
13. Briau R. La Chirurgie de Paul d’Égine. Text Grec … avec Traduction
Française en regard. Paris: Masson; 1855.
14. Gurunluoglu R, Gurunluoglu A. Paulus Aegineta, a Seventh
Century Encyclopedist and Surgeon: his Role in the History of
Plastic Surgery. Plast Reconstr Surg. 2001;108:2072–2079.
15. Tabanelli M. Tecniche e Strumenti Chirurgici del XIII e XIV secolo.
Firenze: Olschki; 1973.
16. Paré A. Les Oeuvres. Paris: Buon; 1575.
17. Bartisch G. Ophthalmodouleia, das is Augendienst. Dresden: Stöckel;
1583.
18. Gnudi MT, Webster JP. The Life and Time of Gaspare Tagliacozzi. New
York: Reichner; 1950.
19. Fioravanti L. Il Tesoro della Vita Humana. Venice: Sessa; 1570.
20. Cortesi GB. Miscellaneorum Medicinalium Decades Denae. Messina:
Brea; 1625.
21. Carpue JC. An Account of Two Successful Operations for Restoring a
Lost Nose from the Integuments of the Forehead, in the Case of Two
Officers of his Majesty’s Army. London: Longman, Hurst; 1816.
22. Gräfe CF. Rhinoplastik: oder die Kunst den Verlust der Nase organisch
zu ersetzen. Berlin: Realschulbuchhandlung; 1818.
23. Dieffenbach JF. Chirurgiche Erfahrungen. Berlin: Enslin;
1829–1834.
24. Delpech JM. Sur l’opération de la rhinoplastique. In: Delpech JM,
ed. Chirurgie Clinique de Montpellier. Vol. II. Paris: Gabon; 1828:221.
25. Pancoast J. A Treatise on Operative Surgery; comprising a Description of
the Various Processes of the Art, including All New Operations.
Philadelphia: Carey and Hart; 1844.
26. Balassa J. Uj Mütétmodorok az Orrképlés Körül két Kòresettel és
Tizenegy Köre rajzolt Tàblàval. Pest: Emich; 1863.
27. Sabattini P. Cenno storico dell’origine e progressi della Rinoplastica e
Cheiloplastica seguita dalla descrizione di queste operazioni praticamente
eseguite sopra un solo individuo. Bologna: Belle Arti; 1838.
28. Nélaton C, Ombrédanne L. La Rhinoplastie. Paris: Steinheil; 1904.
29. McDowell F. History of rhinoplasty. Aesth Plast Surg.
1978;1:321–348.
30. Rogers BO. Nasal reconstruction 150 years ago: aesthetic and other
problems. Aesth Plast Surg. 1981;5:283–327.
31. Mazzola RF. Reconstruction of the nose. A historical review.
Handchir Mikrochir Plast Chir. 2007;39:181–188.
32. Gräfe CF. Die Gaumennaht, ein neuentdecktes Mittel gegen
angeborene Fehler der Sprache. J Chir Augenheilk. 1820;1:1–54.
33. Roux PJ. Observation sur une division congénitale du voile du
palais et de la luette guérie au moyen d’une opération analogue à
celle du bec de lièvre. J Univers Sci Med. 1819;16:356.
34. Langenbeck BRC. Die Uranoplastik mittelst Ablösung des mucös-
periostalen Gaumenüberzuges. Arch kl Chir. 1862;2:205–287.
35. Malgaigne JF. Nouvelle Méthode pour l’opération du bec de lièvre.
J Chir. 1844;2:1–6.
36. Mirault G. Lettre sur l’opération du bec de lièvre. J Chir.
1844;2:257–263.
37. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin
Plast Surg. 1984;11:583–617.
38. Mazzola RF, Hueston JT. A forgotten innovator in facial
reconstruction: Pietro Sabattini. Plast Reconstr Surg. 1990;85:621–626.
39. Bruns V von. Chirurgischer Atlas. Bildliche Darstellung der
chirurgischen Krankheiten und der zu ihrer Heilung erforderlichen
Instrumente, Bandagen und Operationen. II Abt. Kau- u. Geschmaks-
Organ. Tübingen: Laupp; 1857–1860.
40. Fricke JCG. Die Bildung neuer Augenlider (Blepharoplastik) nach
Zerstörungen und dadurch hervorgebrachten Auswärtswendungen
derselben. Hamburg: Perthes und Besser; 1829.
41. Klasen HJ. History of Free Skin Grafting. Berlin: Springer; 1981.
42. Baronio G. Degli Innesti Animali. Milan: Stamperia del Genio; 1804.
43. Baronio G. On Grafting of Animals. Boston: Boston Medical Library;
1985.
44. Reverdin JL. Greffe Epidermique. Expérience faite dans le Service
de M. le Docteur Guyon à l’Hôpital Necker. Bull Soc Imp Chir Paris.
1870;2 sér, 10:511–515.
45. Ollier LXEL. Greffes Cutanées ou Autoplastiques. Bull Acad Méd.
1872;1:243–250.
46. Thiersch C. Über die feineren anatomischen Veränderungen bei
Aufheilung von Haut auf Granulationen. Verh deutsch Ges Chir.
1874;3:69–75.
47. Wolfe JR. A new method of performing plastic operations. Br Med J.
1875;2:360–361.
48. Filatov VP. Plastika na kruglom steb (Plastic procedure using a
round pedicle). Vestnik Oftalmol. 1917;34:149–158.
49. Gillies HD. Plastic Surgery of the Face. London: Frowde, Hodder and
Stoughton; 1920.
50. Lexer E. Wiederherstellungschirurgie. Leipzig: Barth; 1920.
51. Esser JFS. Die Rotation der Wange und allgemeine Bemerkungen bei
chirurgischer Gesichtsplastik. Leipzig: Vogel; 1918.
52. Esser JFS. Biological or Artery Flaps of the Face. Monaco: Institut Esser
de Chirurgie Structive; 1935.
53. Mazzola RF, Kon M. EURAPS at 20 years. A brief history of
European Plastic Surgery from the “Société Européenne de
Chirurgie Structive” to the “European Association of Plastic
Surgeons” (EURAPS). J Plast Reconstr Aesthet Surg. 2010;65:888–895.
54. Rogers BO. U.S. plastic surgeons who contributed to the Revue
de Chirurgie Plastique and the Revue de Chirurgie Structive
(1931–1938): “Giants” in our specialty. Aesthetic Plast Surg.
1999;23:252–259.
55. Manchot C. Die Hautarterien des menschlichen Körpers. Leipzig: Vogel;
1889.
56. Tansini I. Sopra il mio nuovo processo di amputazione della
mammella. Gazz Med It. 1906;57:141.
57. Tessier P, Guiot G, Rougerie J, et al. Ostéotomies cranio-naso-orbito-
faciales. Hypertélorisme Ann Chir Plast. 1912;669–712.
58. Mazzola RF, Mazzola IC. History of fat grafting. From ram fat to
stem cells. Clin Plastic Surg. 2015;42:147–153.
59. Dieffenbach JF. Die operative Chirurgie. Leipzig: Brockhaus; 1845.
60. Szymanowski J von. Operatzij na poverchnosti Tchelovetcheskago
Tela. Kiev: Davidenko; 1865.
61. Rogers BO. A chronologic history of cosmetic surgery. Bull NY Acad
Med. 1971;47:265–302.
62. Roe JO. The deformity termed “Pug-Nose” and its correction by a
simple operation. Med Rec. 1887;31:621–623.

23.e2
CHAPTER 2 • History of reconstructive and aesthetic surgery
63. Roe JO. The correction of angular deformities of the nose by a
sub-cutaneous operation. Med Rec. 1891;40:57–59.
64. Weir RF. On restoring sunken noses without scarring the face. NY
Med J. 1892;56:449–454.
65. Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst einem Anhang
über Mammaplastik. Leipzig: Kabitzsch; 1931.
66. Haiken E. Venus Envy. A History of Cosmetic Surgery. Baltimore:
Hopkins University Press; 1997.
67. Miller CC. Cosmetic Surgery. The Correction of Featural Imperfections.
Chicago: Oak Printing; 1907.
68. Miller CC. Rubber and Gutta-Percha Injections. Chicago: Oak Printing;
1923.
69. Maliniak JW. Sculpture in the Living. New York: Pierson; 1934.
70. Maliniak JW. Rhinoplasty and Restoration of Facial Contour.
Philadelphia: Davis; 1947.
71. Smith F. Reconstructive Surgery of the Head and Neck. New York:
Nelson; 1928.
72. Nöel S. La Chirurgie Esthétique. Son rôle sociale. Paris: Masson; 1926.
73. Passot R. La Chirurgie Esthétique pure. Technique et Résultats. Paris:
Doin; 1931.
Further reading
Aufricht G. Development of Plastic Surgery in the United States. Plast
Reconstr Surg. 1946;1:3–25.
Mazzola RF. History of Esthetic Rhinoplasty. In: Peled IJ, Manders EK,
eds. Esthetic Surgery of the Face. London: Taylor & Francis;
2004:171–189.
McDowell F. The Source Book of Plastic Surgery. Baltimore: Williams &
Wilkins; 1977.
Santoni-Rugiu P, Sykes PJ. A History of Plastic Surgery. Berlin: Springer;
2007.
74. Bourguet J. Notre traitement chirurgical de «poches» sous les yeux
sans cicatrice. Arch Fr Belg Chir. 1928;31:133–136.
75. Holländer E. Die kosmetische Chirurgie. In: Joseph M, ed. Handbuch
der Kosmetik. Leipzig: Von Veit; 1912.

3 
Psychological aspects of cosmetic surgical
and minimally invasive treatments
David B. Sarwer and Mark B. Constantian
Disclosures: Dr. Sarwer has consulting relationships with Kythera, Medtronic, and Neothetics.
SYNOPSIS
■ The last two decades have witnessed a dramatic increase in the
number of persons who undergo cosmetic surgery and minimally
invasive medical treatments designed to improve their appearance.
■ Plastic surgeons have long been interested in the psychological factors
that motivate individuals to undergo these procedures as well as the
psychological changes that they frequently observe postoperatively.
■ Early reports in this literature characterized most persons interested in
changing their appearance with cosmetic surgery as suffering from a
range of psychopathological conditions.
■ More recent investigations of patients have focused on
psychopathology but also other motivations.
■ Body image dissatisfaction is commonly believed to be one of the
strongest motivations for surgery. For some patients, however, this
dissatisfaction may be severe and suggestive of the presence of body
dysmorphic disorder or other forms of psychopathology with a body
image component. Thus, these conditions are likely of greatest
relevance to plastic surgeons.
The popularity of cosmetic surgical
and minimally invasive treatments
According to the American Society of Plastic Surgeons, 15.6
million cosmetic surgical and minimally invasive treatments
were performed in 2014.1 The vast majority, nearly 14 million,
were minimally invasive procedures such as Botox® injections
and soft tissue fillers. Over 1.6 million were the traditional
cosmetic surgical procedures such as breast augmentation
and rhinoplasty. The total number of procedures has increased
by 111% since 2000.1 While these numbers certainly reflect the
popularity of cosmetic procedures, they likely underestimate
the true number of procedures performed annually in the
United States, as physicians from specialties other than plastic
surgery now offer many of these treatments.
There are a number of potential explanations for the
growth in popularity in cosmetic surgery and minimally
invasive treatments.2,3 Many treatments are safer and have
shorter recovery periods than before. The shorter recovery
period, as well as the much lower cost of minimally inva­
sive treatments, have facilitated their rapid growth over the
decade. Cosmetic procedures readily lend themselves to
direct-to-consumer advertisements. In most major metropoli­
tan areas, advertisements for these procedures are frequently
seen on billboards and in local magazines. This marketing
likely has contributed to the growth. The larger mass media
and entertainment industries likely have contributed as well.
Cosmetic surgery has long been a very popular topic for
women’s (and men’s) fashion and beauty magazines, where
articles often describe the latest advances in the field. The past
decade also witnessed unprecedented coverage of cosmetic
surgery on television, both in traditional media coverage and
as the focus of reality-based television programs.5 At the same
time, a growing number of celebrities publicly revealed their
experiences with cosmetic surgery, a phenomenon not seen
in Hollywood decades ago. These more overt influences play
against a backdrop of relentless images of physical perfection
depicted in magazines, television programs, movies, and the
internet. The end result is that consumers can’t help but be
exposed to depictions of beauty as well as the message that
cosmetic medical treatments are part of the path to physical
perfection.
There are other potential explanations for the growth of
cosmetic surgery as well. Evolutionary theories of physical
attractiveness – which suggest that physical characteristics
that demonstrate reproductive potential are the ones that are
often seen as being most physically attractive – may play a
role. Many facial procedures are undertaken to help an indi­
vidual look more youthful and/or enhance their facial sym­
metry, key markers of physical attractiveness. Liposuction
and abdominoplasty can decrease an individual’s waist-to-
hip ratio, which is another demonstrated marker of reproduc­
tive potential and “signal” of physical attractiveness.

25
Body image dissatisfaction as a motivation for cosmetic medical treatment
Body image dissatisfaction as
a motivation for cosmetic
medical treatment
Patients present for cosmetic medical treatments with a
variety of motivations. These motivations have been described
as internal (e.g., desire to improve one’s self-esteem) or exter­
nal (e.g., undergoing surgery in order to find a romantic
partner).18 Although patients may struggle to verbalize their
specific motivations for surgery to others (including friends,
family members, and their treating physician), those with
internal motivations are thought to be more likely to have
their postoperative expectations met.19
Body image dissatisfaction is believed to be the most
common motivation for a cosmetic procedure. The last several
decades have witnessed a growing interest in the psychologi­
cal construct of body image.20 Body image has been defined
in several ways. A commonly used definition suggests that
body image consists of perceptions, thoughts, and feelings
associated with the body and bodily experience. While this
definition describes the multidimensional nature of the con­
struct, it does not highlight body image behaviors, such as
motivations for changing one’s appearance through cosmetic
procedures. Cash and Smolak have described body image as
“the psychological experience of embodiment”.21 This descrip­
tion conveys a sense of importance of the role of body image
in larger psychological constructs like quality of life.
Body image is believed to contribute to self-esteem and
quality of life.22,23 Much of the early research on body image
focused on the weight and shape concerns of individuals with
eating disorders. As research into the global obesity problem
matured in the 1990s, the body image concerns of overweight
and obese individuals garnered more attention.24 Body image
concerns can be thought of as both global and specific. Body
image dissatisfaction is often correlated with body weight.22
However, the strength of this relationship is not as strong as
would be intuitively thought. This finding is consistent with
theories of body image, which have suggested that there may
be little relationship between what one thinks about the body
and the objective reality of one’s appearance.21
Independent of body weight, most individuals also report
more concerns with specific features of their appearance. This
is particularly true among individuals who presented for
cosmetic procedures, who often report dissatisfaction focused
on a given feature rather than a more global dissatisfaction
with their entire body. Women are typically far more dissatis­
fied with their body image than men.23 Differences also exist
across ethnic groups. African-American women, as compared
to Caucasian women, typically report less body image dis­
satisfaction. Among ethnic groups, body image dissatisfaction
appears to be related to the degree of acculturation into more
Westernized lifestyles.
Some degree of body image dissatisfaction appears to be
“normative” in Western society and likely results from soci­
ety’s pervasive emphasis on thinness as the ideal body type.
Body image dissatisfaction is believed to motivate a number
of appearance-enhancing behaviors, including weight loss,
physical activity, fashion and cosmetic purchases, and cos­
metic procedures.24 Body image dissatisfaction, and its role in
the pursuit of cosmetic medical treatments, has been the focus
Social psychological research on the role of physical
appearance in daily life also can be used to understand the
growth of cosmetic surgery as well as other appearance-
enhancing behaviors. This research repeatedly has found that
individuals who are more physically attractive are judged to
have a number of more positive personality traits and receive
preferential treatment in a range of social situations across the
lifespan.6 With this in mind, interest in cosmetic surgery and
minimally invasive treatments share similarities with other
self-enhancement strategies, such as eating a healthy diet and
exercising regularly.7
Psychosocial characteristics of
patients interested in cosmetic surgery
and minimally invasive treatments
Over the last 60 years, a large body of research on the psycho­
logical aspects of cosmetic surgery and minimally invasive
treatments has developed.8 Many studies have investigated
the psychological characteristics of patients who pursue these
procedures; others have looked at the relationship of these
characteristics to treatment outcomes. The first studies of this
issue, conducted by plastic surgeons in collaboration with
psychiatrists (many of whom appeared to be working from a
psychodynamic theoretical orientation) involved clinical
interviews of patients prior to their procedures. Perhaps not
surprisingly, these studies described large numbers of patients
as suffering from significant psychopathology.9,10 Large
numbers of individuals were characterized as suffering from
depression, personality disorders (typically narcissistic per­
sonality disorder) and even schizophrenia. Many of these
early reports also contain elaborate interpretations of the role
of unconscious conflicts and poor parental relationships in the
decision to seek surgery. There is no evidence, however, to
suggest that such interpretations are necessarily valid or
useful in determining patients’ appropriateness for surgery.11,12
As could be anticipated, those patients suffering with these
issues were thought to be likely to experience poor postopera­
tive psychological outcomes.
Studies conducted since the 1980s typically have included
the use of psychometric measures of personality characteris­
tics rather than or in addition to clinical interviews of prospec­
tive patients. These studies, as compared to the previous
investigations, typically have found less psychopathology.13–16
Nevertheless, both sets of studies suffer from methodological
problems that have made interpretation of these conflicting
findings difficult.11,12,17 Thus, the rate of psychopathology
among cosmetic surgery patients remains poorly understood.
Perhaps more importantly, the relationship between preopera­
tive psychopathology and postoperative outcomes, with few
exceptions, is largely unknown.
Much of the more contemporary research on the psychoso­
cial characteristics of cosmetic surgery patients has focused
on two issues. The first is the motivations of persons who
present for these procedures; body image dissatisfaction is
believed to be central to these motivations. The second is
the occurrence of formal psychopathology and whether the
presence of significant psychiatric illness contraindicates
treatment.

26
CHAPTER 3 • Psychological aspects of cosmetic surgical and minimally invasive treatments
in situations where their perceived “defect” may be more
noticeable to others (e.g., a woman with concerns about her
nose size may report self-consciousness when someone sits
next to her at a restaurant). Still, others may avoid such situ­
ations or engage in camouflaging behaviors. These examples
of concerns and behaviors, while indicative of body image
dissatisfaction, likely do not meet the third criteria for BDD
(experiencing clinically significant distress or impairment in
social, occupational, or other important areas of functioning).
However, a patient who is reporting symptoms of anxiety and
depression because of her nose, or who is socially isolated or
unable to work because of her appearance concerns, likely
would meet diagnostic criteria. Thus, in cosmetic settings, the
degree of distress and impairment in functioning experienced
by the patient likely differentiates a cosmetic surgery patient
with “normative” body image dissatisfaction from one who
is in fact suffering from BDD.38,39
Rates of BDD among cosmetic
treatment populations
A number of studies have investigated the rate of BDD among
individuals presenting for cosmetic surgery.40 Among Ameri­
can samples, rates of 7–13% have been reported.7,41,42 Interna­
tional studies have reported rates ranging from 2.9%–53%.43–51
Studies with the highest rates of BDD have typically used
unspecified clinical interviews to establish the diagnoses.
Thus, there are concerns about the validity of these results.
International studies which have used more rigorous methods
have found rates ranging from 3.2 to 16%.
Seven studies have investigated the rate of BDD among
patients seeking rhinoplasty and reported rates ranging from
12–33%.52–56 The higher rates reported among rhinoplasty
patients is not surprising given that the nose is one of the most
common areas of concern among persons with BDD.57 Among
13 patients seeking Botox® injections for perceived hyperhi­
drosis, 23% met criteria for BDD.58 In a study of 137 patients
in Australia, 2.9% met criteria for BDD.43 Investigators have
also turned their attention to evaluating BDD among patients
seeking less common procedures, including requests for
genital cosmetic surgery. Veale and colleagues found that
18% of women seeking labiaplasty met criteria for the
diagnosis.59,60
BDD is similarly common among persons who seek der­
matological treatment, with rates typically ranging from
4.2–15%.50,61–68 Acne patients treated with isotretinoin (Accu­
tane) have been found to be twice as likely to meet criteria for
BDD,66 a finding that is of interest given the association
between suicidality and use of this treatment as well as the
high rates of suicidal ideation and attempts reported among
those with BDD.69
BDD also has been studied among persons seeking recon­
structive procedures. Three studies have examined the rate of
BDD among persons seeking reconstructive surgical proce­
dures, such as scar revision and breast reconstruction, with
2–16% of patients reporting distress or concern with their
appearance consistent with BDD.41,42,70 A recent study exam­
ined BDD symptoms among 188 women undergoing breast
reconstruction secondary to mastectomy; 17% met criteria for
BDD, and women undergoing delayed reconstruction (versus
immediate) were more likely to meet criteria.71 Although
women with actual breast deformities due to mastectomy
of much of the recent study of cosmetic surgery patients.25–27
Individuals who seek cosmetic procedures typically report
heightened body image dissatisfaction preoperatively.7,28–31
For example, breast augmentation candidates report greater
dissatisfaction with their breasts compared to other small-
breasted women who do not seek breast augmentation.13,15
Similarly, individuals interested in rhinoplasty reported more
appearance concerns as compared to those of age- and gender-
matched controls presenting for non-appearance-altering
surgery.32 Thus, some degree of body image dissatisfaction is
believed to be a prerequisite to cosmetic surgery. At the same
time, body image dissatisfaction, particularly extreme body
image dissatisfaction that impacts daily functioning, is a
symptom of a number of psychiatric disorders. These include
eating disorders, social anxiety disorder, and gender dyspho­
ria. While all psychiatric disorders are likely to be represented
among the large population of persons presenting for cosmetic
treatments, the psychiatric disorder with perhaps the greatest
relevance to cosmetic medical treatment is body dysmorphic
disorder. At the same time, eating disorders and depression
also warrant particular attention.
Formal psychopathology among
patients interested in cosmetic surgical
and minimally invasive treatments
Body dysmorphic disorder
Body dysmorphic disorder (BDD) is characterized as a preoc­
cupation with a slight or nonobservable defect in appearance
that is associated with obsessive thinking and compulsive
behaviors and which leads to a disruption in the activities of
daily life.33 Case reports of patients who likely had the disor­
der, described as “minimal deformity” or “insatiable” patients,
appeared in the plastic surgery and dermatology literatures
in the 1960s and 1970s.34–37 These case reports, appearing
nearly two decades before BDD was formally recognized as a
psychiatric disorder, detailed patients who requested multiple
procedures to improve slight or imagined defects in appear­
ance; most reported significant dissatisfaction with postopera­
tive treatment as well.
Identifying and diagnosing BDD in cosmetic treatment
settings can be challenging.38,39 According to DSM-5’s first
diagnostic criterion for BDD, an individual must be preoc­
cupied with one or more perceived defects in appearance
which are either “slight” or nonobservable to others.33 Most
patients presenting for cosmetic treatments have “normal”
features that that they wish to enhance; others may desire
correction of slight imperfections. Thus, the majority of
patients could meet this criterion.
The second diagnostic criterion describes engagement in
repetitive, appearance-focused behaviors, such as comparing
one’s appearance to that of other people or repeatedly check­
ing one’s appearance in the mirror. Many cosmetic medical
patients engage in these behaviors; others report that they
have spent large amounts of time reviewing images of celebri­
ties in order to find examples of how they wish specific features
to look. It is not uncommon for individuals who seek cosmetic
treatments to report self-consciousness in social situations or

27
Formal psychopathology among patients interested in cosmetic surgical and minimally invasive treatments
study of 127 women who had undergone cosmetic treatment
reported that women with higher levels of BDD symptoms
were more likely to be dissatisfied with their treatment
outcome and were more likely to have ever been rejected
for cosmetic treatments compared to those with low BDD
symptom levels.82 Phillips et al. conducted a prospective, natu­
ralistic study of 161 individuals diagnosed with BDD and
found that receipt of cosmetic treatment did not predict remis­
sion from BDD one year later.83 Overall, these findings are
consistent with retrospective reports regarding the likelihood
of poor outcomes following cosmetic treatments among
persons with BDD.
In contrast, two recent studies have suggested that some
individuals with BDD may benefit from cosmetic treatments.
A prospective study of 31 patients with mild to moderate BDD
who sought and received rhinoplasty found that, postopera­
tively, 81% had a complete remission of BDD symptoms; 90%
were satisfied with their postoperative outcome.84 However,
this study had some significant limitations, such as the small
sample and inclusion of patients who were rated as having
“marked nasal deformity” (calling into question whether they
would meet diagnostic criteria for BDD). Thus, the conclusion
that rhinoplasty benefits patients with mild to moderate BDD
is likely unfounded.85 Another recent prospective study of
women seeking labiaplasty (n = 49), nine of whom met criteria
for BDD via self-report and clinical interview preoperatively,
found that eight experienced a remission from BDD symp­
toms at a 3-month postoperative assessment,60 and four
reported longer-term remission from BDD. Interestingly, the
one woman who still met criteria for BDD postoperatively did
so because of a different appearance preoccupation (nose) but
reported satisfaction with her labiaplasty.
In addition to the risks for poor outcomes and dissatisfac­
tion with treatment, patients with BDD are known to have
high risks for suicide. The mean annual suicide attempt rate
for persons with BDD is 2.6%, while the mean suicidal ide­
ation rate is 57.8%.69 Unmet cosmetic treatment expectations
could fuel suicidal ideation and/or suicide attempts in some
patients with BDD. Treating physicians also face risks when
knowingly or unknowingly performing cosmetic procedures
on patients with BDD. At a minimum, patients with BDD may
present as being “difficult” or hard to manage for providers
and their staff.86,87 Providers may also face legal risks, as
patients with BDD have threatened or pursued legal action
against their treating physicians.42,76,77 Surveys of cosmetic
treatment providers suggest that between 9% and 29% of
physicians have been threatened legally by a patient with
BDD.76,77 Two percent of cosmetic and dermatological sur­
geons report being threatened with physical harm by patients
with BDD. Tragically, some providers have been murdered by
patients with or suspected of having BDD.88
Due to the safety risks for both patients and providers along
with the evidence that cosmetic treatment outcomes among
persons with BDD are typically poor, BDD appears to be a
contraindication for cosmetic treatments. Given that persons
with BDD frequently seek cosmetic treatments, screening for
BDD is recommended in cosmetic treatment settings.
Clinical presentation of patients with BDD
A number of still-unanswered questions emerge from the
body image and body dysmorphic disorder literature: (1)
would likely not meet full criteria for BDD, individuals
with objective defects can become preoccupied with their
appearance and experience significant distress and functional
impairment.
Use of cosmetic medical treatments among
individuals with BDD
A number of studies have investigated the history of cosmetic
procedures among persons with an established diagnosis
of BDD.72–74 In one of the earliest studies, 48% of individuals
with BDD reported having sought cosmetic or dermatological
treatment, with 26% having undergone one or more cosmetic
procedures.74 Two larger studies have suggested that over
70% of patients had sought and more than 64% had received
a cosmetic treatment.72,73 These reports are not particularly
surprising. Individuals with BDD believe, often with delu­
sional intensity, that their appearance is truly flawed. Many
believe that the only way to reduce their appearance-related
distress is to actually change their appearance via cosmetic
medical treatment. In fact, individuals with BDD are nearly
as likely to pursue treatments from dermatologists, parapro­
fessionals, and plastic surgeons as they are from psychologists
or psychiatrists.75
While many individuals with BDD are able to obtain cos­
metic treatments, a sizable percentage report that they were
unable to receive a desired treatment. Surveys suggest that
80% of plastic surgeons and 62% of dermatologic surgeons
have refused to perform cosmetic procedures on individuals
believed to have BDD.76,77 Unfortunately, in today’s competi­
tive cosmetic procedure market, patients with BDD who are
denied treatments by one provider can engage in “doctor
shopping” until they find a provider willing to perform their
desired procedure.
In some instances, patients with BDD can become so dis­
tressed about their perceived appearance defects that they
take matters into their own hands and perform “do-it-your­
self” procedures.78,79
Cosmetic treatment outcomes among persons
with BDD
Individuals with BDD are often convinced that cosmetic treat­
ments will alleviate their appearance-related preoccupation
and distress. However, evidence suggests that cosmetic
treatments rarely improve BDD and patients are frequently
dissatisfied with treatment outcomes.72,74,78,79 For example,
a study of 200 persons with BDD found that only 3.6% of
528 procedures resulted in improvement in overall BDD
symptoms.72
Few studies have prospectively examined cosmetic treat­
ment outcome among individuals with BDD. Tignol and
colleagues80 evaluated 24 cosmetic surgery patients who
sought treatment for minimal appearance defects; 10 of these
patients had been diagnosed with BDD preoperatively. Five
years later, seven of the ten patients had undergone cosmetic
surgery. Among these seven, remission was reported by only
one, while the other six continued to meet diagnostic criteria
for BDD. New areas of concern developed in five patients. A
prospective study of 166 individuals who sought rhinoplasty
found that greater preoperative BDD symptoms predicted
dissatisfaction with treatment postoperatively.81 Similarly, a

28
CHAPTER 3 • Psychological aspects of cosmetic surgical and minimally invasive treatments
These observations led to further study of the psychosocial
history of 100 secondary rhinoplasty patients.91,92 Half of the
patients originally had noses with dorsal humps (the most
common motivation for rhinoplasty), and half originally had
straight noses. Twenty-nine had straight, functional noses that
the patients knew were normal; yet they had surgery anyway.
The data suggested that the smaller the deformity, the greater
the likelihood of depression, history of childhood trauma, and
the lower the patients’ satisfaction with the surgical results.
Secondary rhinoplasty patients who originally had straight
noses had undergone three times as many rhinoplasties and
had three times the trauma prevalence of patients who origi­
nally had dorsal humps. Among 29 patients who were
depressed, had undergone more than three cosmetic opera­
tions of any type, and whose motivation for the first rhino­
plasty had been to “perfect” a subjectively normal nose (which
defines body dysmorphic disorder), the prevalence of child­
hood trauma was an astonishing 93%. The surgical satisfaction
rate after one operation was only 3%. Subsequent studies have
indicated that many revision rhinoplasty patients also screen
positive for post-traumatic stress disorder, especially if
they had childhood trauma histories, and that successful
reconstructive surgery can decrease their avoidance and re-
experiencing symptoms.93 Mediation analysis indicated that a
history of childhood abuse or neglect was the most significant
factor connecting patient satisfaction and the number of pre­
vious surgeries; in other words, childhood trauma patients
had undergone the most cosmetic surgeries and were the
most likely to be unhappy with the results of additional
procedures.91 Random forest analysis indicated that the
number of prior surgeries was the most significant predictor
of surgical success for patients who originally had dorsal
humps, but that childhood trauma was the most significant
factor predicting success for patients who originally had
straight, normal noses.92
Childhood trauma is implicated in many types of diseases,
including chronic pain syndromes, fibromyalgia, cardiovas­
cular and pulmonary disease, cancer, asthma, morbid obesity,
mental health disorders, and autoimmune disease, which
accounts in part for the reported incidence of body dysmor­
phic disorder even in reconstructive patients.70,71,88,94,95–99 Of
particular interest and relevance to plastic surgeons is the
connection between childhood trauma, eating disorders, and
body image. A number of studies have shown a strong
correlation between body image and childhood trauma,
parti­cularly sexual abuse, depression, eating disorders, and
obesity.97,99–101
What evidence is there that BDD patients display signs of
neglect or abuse? One study indicated that 78.7% of 75 patients
with confirmed BDD had histories of neglect or abuse.89 Other
reports document associated traits: poor social functioning,
social anxiety, depression, anxiety, anger, and somatic symp­
toms, neuroticism, eating disorders, post-traumatic stress
disorder, and obsessive compulsive disorder.102–112
To date, efforts to identify abnormalities in neuroanatomy,
neurotransmitters, or genetic expression or allelic variation
have not yielded consistent information about the pathogen­
esis of body dysmorphic disorder. However, fMRIs of body
dysmorphic patients have documented overactivity in the
thalamus and amygdala and a left-to-right volume asymmetry
in the caudate nucleus, changes that are coincidentally con­
sistent with findings in patients with histories of childhood
What drives patients with normal features or minimal defor­
mities to undergo repeated plastic surgeries on one or more
body areas? (2) Why is there often such poor correlation
between the degree of preoperative deformity and the drive
to surgery that it provokes? (3) Why are patients who have
undergone multiple cosmetic surgeries so likely to be unhappy
with their surgical results, even when they appear to be suc­
cessful? (4) If body dysmorphic disorder is driven by the
media and the obsession of popular culture with beauty and
being thin, why are some reconstructive patients just as dif­
ficult to please?88 (5) Why do some postoperative patients
become so irrationally angry that they are beyond reason? (6)
Finally, why do many of these unhappy patients have turbu­
lent family relationships?
Twenty years ago, one of us (MBC) saw three patients in
relatively quick succession who all had tumultuous postop­
erative courses after reconstructive nasal surgery – doubly
ironic because each patient had an entirely successful surgical
outcome. One was a university professor who resigned her
position to become a recluse because she believed that her
reconstructed nose now pointed toward the ceiling. She
remained inconsolable by logic or photographic analysis.
When I advised against further surgery, she wrote a letter that
concluded, “I feel so terribly betrayed…You have robbed me
of my family, my friends, and my joy in living.” The second
patient was a physician’s wife who hid in her bedroom for
months after surgery, unable to function or care for her family
because of perceived but invisible nasal deformities. The third
patient abandoned his business, abused alcohol heavily, and
unsuccessfully tried to amputate his reconstructed nose.78 All
of these patients seemed like excellent surgical candidates
preoperatively but revealed themselves to meet the diagnostic
criteria for BDD after surgery. Postoperatively, they could not
be reassured: all were convinced that their results were fail­
ures and that they needed additional surgery.
Soon thereafter, a young man came for secondary rhino­
plasty who said, “I had body dysmorphic disorder but I have
recovered.” With the approval of his therapist, one of us
(MBC) performed his revision rhinoplasty. His postoperative
course was smooth. Later, the surgeon requested a letter
describing his body dysmorphic disorder experience, since
most surgeons had never treated patients who recovered.
His four-page, single-spaced autobiography chronicled an
intense, traumatic childhood, the desertion of his father, an
abusive stepfather who relentlessly ridiculed the child’s nose,
family alienation, his brother’s suicide, drug abuse, and his
mother’s abandonment. This observation led to further
speculation on the relationship between BDD and childhood
abuse or neglect, which was subsequently reported in the
literature.89
This hypothesis led to a report of 20 secondary rhinoplasty
patients with similar personal and family characteristics who
had undergone a total of 134 rhinoplasties, almost 7 each.90
All had undergone multiple rhinoplasties and other cos­
metic operations; they were perfectionistic, demanding, and
depressed; and 80% of their original unoperated noses had
been straight and symmetrical. When asked, “Why did you
have surgery?” they gave answers like these: “Because my
nose wasn’t perfect enough”; “Because my mother wanted me
to be as beautiful as she was”; “Because my mother told me,
‘You were the ugliest baby I ever saw’”; and perhaps the
saddest one, “I had surgery so people would love me.”

29
Formal psychopathology among patients interested in cosmetic surgical and minimally invasive treatments
The shadow factor of childhood abuse and neglect, so
regrettably common in our culture, may, in part, explain why
the severity of our patients’ deformities does not always cor­
respond to the drive for surgery that it provokes, why so
many of their lives and family relationships are chaotic, and
why it is so hard to reason with some unhappy patients. The
trauma link complements what is currently known about
body dysmorphic disorder and may be one of the keys to
understanding some of our unhappiest plastic surgery
patients.
Depression
The potential presence of major depression or other mood
disorders also warrants particular attention by the physician
offering cosmetic treatments. At least one study has sug­
gested that approximately 20% of persons presenting for
cosmetic surgery are engaged in mental health treatment,
most typically the use of an antidepressant or other psychi­
atric medication.111 Women considering breast augmentation
or those with breast implants have been found to report a
higher rate of outpatient psychotherapy,15 psychopharmaco­
logic treatments,111 and psychiatric hospitalizations,112 as
compared to other cosmetic surgery patients or women
from the general population. Although these studies suggest
that the rate of psychopathology may be higher among
patients with breast implants, the investigations provided
no information on the specific psychiatric diagnoses of these
women.
Table 3.1  Characteristic behaviors of disempowered and falsely empowered patients
Disempowered patients
Falsely empowered patients
No self-esteem
Unjustifiably untrusting or fearful
Unable to make decisions
Unsure of themselves or surgeon
Require extra time of surgeon and staff
Manifest victim behavior
Grandiosity
False sense of superiority
Try to dictate operative plan
Expect to be seen on holidays or weekends
Demand extra time of surgeon and staff
Request special fees and/or discounts
Overly sensitive to surgical advice
Take everything as criticism
No sense of humor
May exercise covert manipulations
Argue
Interrupt
May act offensively or manipulatively and try to control the surgical
process
Unable to articulate surgical goals
Seem inarticulate, disconnected, non-relational
Have exaggerated or imperceptible deformities
May have controlling parents or spouse
Unrealistically precise about surgical goals
Expect perfection
Have exaggerated or imperceptible deformities
Argumentative with staff
Possible histories of alcohol abuse and/or antidepressant use
Depression, migraines, fibromyalgia
Eating disorders or obsessive compulsive behavior
History of multiple surgeries without adequately considering risks
Possible histories of stimulant use, risk-taking, gambling, high-risk
sports or professions
Work or sex addictions
High-intensity lives
History of multiple surgeries without adequately considering risks
Unable to perform simple postsurgical care
Forget appointments, unable to make decisions
Do not remember or follow written instructions
Request and need constant advice and reassurance via phone or
email
May self-injure, become reclusive or threaten suicide
Disregard perioperative instructions
Demand extra, holiday, or weekend appointments
Arbitrarily alter perioperative instructions
Act entitled
Guarded; remote; may reject routine postoperative care
May become aggressive or threatening
May have body shame
May have body shame
trauma and post-traumatic stress disorder.108 Adding even
further complexity is recognition that family environment
influences genetic factors, which in turn work together to
create both personality and psychopathology. Although only
a small number of genes have been studied to date, both
genome-wide association studies and epigenetic research
have documented variations in the hypophyseal–pituitary
axis and dopamine and serotonin transmission that may affect
susceptibility to trauma or, conversely, produce resilience.109
What are the clinical implications of these relationships?
Most plastic surgeons do not routinely take trauma histories
or inquire about their patients’ childhoods, and not every
person subjected to abuse or neglect is susceptible to their
damaging effects. Yet all patients have life histories. Abuse by
caregivers may be disempowering or falsely empowering,
distorting or destroying the traits that functional adults must
possess: self-esteem, “boundaries” (self-protection and con­
tainment against offending others), a sense of reality, and the
ability to live moderately and independently. Abused and
neglected patients live at the extremes, depending on the
types of trauma they have experienced. For example, disem­
powered patients lack self-esteem, cannot articulate surgical
goals, forget appointments, and may manifest victim behav­
ior; falsely empowered patients become grandiose, demand
extra attention, may dictate the operative plan, and expect
perfection (Table 3.1). Only when surgeons consider their
patients’ pasts will their current behaviors become under­
standable as remnants of adapted responses to abuse or
neglect.110

30
CHAPTER 3 • Psychological aspects of cosmetic surgical and minimally invasive treatments
of aesthetic medical treatments seen in the past two decades.
With the wide range of patients who seek cosmetic surgery,
all psychiatric diagnoses are likely to be found. Most salient
to cosmetic surgery are likely psychiatric conditions with a
body image component – body dysmorphic disorder and
eating disorders as well as depression. Studies suggest that
between 5% and 15% of patients seeking cosmetic surgery
suffer from BDD, indicating that providers may encounter
these patients in their practice on a regular basis. Although it
makes intuitive sense that the weight and shape concerns seen
in eating disorders may be related to interest and pursuit of
cosmetic surgery, research investigating this relationship is
lacking. The most concerning relationship between cosmetic
surgery and psychopathology is the link between breast
implants and suicide. This relationship clearly warrants
further study.
Psychosocial status following cosmetic
medical treatments
Numerous studies have suggested that 80–90% of patients
report satisfaction with the results of their cosmetic medical
treatments.16,119–122 Patients also have been found to report
significant improvements in body image.16,121,123–125 Most
studies have found these changes within the first two years
of surgery, although one investigation has shown improve­
ments in body image enduring for five years after surgery.126,127
Studies of psychosocial functioning beyond body image
have produced mixed results. For example, a number of rela­
tively recent studies have looked at changes in self-esteem
following cosmetic medical treatments. This is a particularly
relevant construct, as these treatments are often marketed
with the promise of improving self-esteem. Some studies have
documented the improvements in self-esteem.127–129 Other
studies have not found statistically significant improve­
ments in self-esteem.130–133 However, this also may be a func­
tion of methodology. For example, if asked directly whether
or not surgery improved self-esteem, women who underwent
breast augmentation report improvements.129,130,133 In contrast,
studies which have used psychometric measures of self-
esteem have found equivocal results.119,121,134–136 At least one
investigation has shown that while self-esteem may improve
in the first few years after surgery,128 these benefits appear to
dissipate over time.
Studies that have investigated the relationship between
cosmetic medical procedures and depression also have
found mixed results. Some reports show an improvement in
depressive symptoms.137–139 In contrast, other studies have
found no appreciable changes in depressive symptoms after
treatment.126,132,140
Postoperative satisfaction and the psychological benefits
associated with cosmetic surgery may be negatively impacted
by the occurrence of a postoperative complication.19 At least
one study found that breast augmentation patients who
experienced postoperative complications reported less favor­
able changes in body image in the first two years following
surgery.124 Statistics from the American Society of Plastic
Surgeons indicate that approximately 50% of patients return
for a second procedure at some point in the future.1 Unfortu­
nately, it is unclear if these patients are returning for a second
procedure because they are dissatisfied with the outcome of
Over the past 15 years, seven epidemiological studies
investigating the relationship between silicone gel-filled
breast implants and all-cause mortality have found an asso­
ciation between breast augmentation and suicide.113 These
studies, which focused on women who received these implants
for cosmetic purposes, suggest that the rate of suicide is two
to three times higher than rates in other cosmetic surgery
patients or estimated rates in the general population. (Women
who received breast implants as part of breast reconstruction
were not studied.) Potential explanations of the relationship
between breast implants and suicide primarily have focused
on the preoperative psychosocial status and functioning of the
women.25,113,114 Women who undergo cosmetic breast augmen­
tation have been shown to have a number of distinguishing
demographic characteristics. They are more likely to report
more lifetime sexual partners and a greater use of oral contra­
ceptives, be younger at the time of their first pregnancy, and
have a history of terminated pregnancies.115,116 They also
have been found to be more frequent users of alcohol and
tobacco.14,116,117 Many of these characteristics are markers of
psychopathology, in and of themselves, risk factors for suicide.
Only one of the seven epidemiological studies provided
any information on the psychiatric history of the women
studied. This study found a higher rate of previous psychiatric
hospitalizations among women with breast implants in com­
parison to both women who received other cosmetic proce­
dures and women who underwent breast reduction.112 A
history of psychiatric hospitalizations is one of the strongest
predictors of suicide among women in the general popula­
tion.118 Unfortunately, Jacobsen and colleagues did not report
information on diagnosis, history of illness, or other psychi­
atric treatments for the women in their sample.112 Thus, more
specific information on the relationship is not available.
Though these studies have documented that there is a rela­
tionship between breast augmentation and suicide, it is
important to note that breast implants or breast augmentation
surgery does not cause suicide. Rather, it appears that the
individual personality characteristics and experiences more
likely contribute to the relationship.
Eating disorders
Given the excessive body image dissatisfaction reported by
patients with eating disorder, these disorders may occur with
some frequency among those who seek cosmetic surgery.
Persons with eating disorders may erroneously believe that
cosmetic treatments will improve their immense dissatisfac­
tion with their bodies. Eating disorders may be a particular
concern for women (and men) who seek body contouring
procedures, including liposuction, abdominoplasty, as well as
breast augmentation. These patients may mistakenly believe
that these procedures can reshape their bodies in a way that
restrictive eating and/or maladaptive compensatory behav­
iors cannot. Women who present for cosmetic breast augmen­
tation are frequently below average weight13,15,31 and report
greater exercise compared to physically similar women not
seeking breast augmentation,13 both of which also may be
suggestive of eating psychopathology.
In summary, the psychological functioning of cosmetic
surgery patients has been of interest to both the physicians
who offer these treatments, as well as mental health profes­
sionals, for decades. This interest predates the prolific growth

31
Motivations and expectations
evaluation should be considered if symptoms do not appear
to be well controlled. If a patient is in treatment with another
mental health professional, the surgeon should contact this
professional and, as appropriate, discuss the patient’s appro­
priateness for treatment.
For patients with current symptoms of BDD or a history of
psychiatric disorders or psychiatric hospitalization, a preop­
erative mental health evaluation is recommended before
proceeding with surgery. If a patient discloses (s)he is cur­
rently receiving psychiatric or psychological treatment, the
surgeon or staff should request permission to contact the
patient’s mental healthcare provider in order to discuss the
appropriateness of surgery. Surgeons should be cautious
about proceeding with surgery if the patient refuses to allow
contact with their mental healthcare provider.
Motivations and expectations
The surgeon also should inquire about motivations and
expectations for aesthetic treatment. In assessing motivations,
the provider may want to ask, “When did you first think
about changing your appearance?” Similarly, it may be
instructive to ask, “What other things have you done to
improve your appearance?” In addition to providing impor­
tant clinical information, these questions also may reveal the
presence of some obsessive or delusional thinking, as well as
compulsive or bizarre behaviors, related to physical appear­
ance. Some patients may report that they have tried several
“do-it-yourself” treatments, such as non-FDA approved treat­
ments, in an attempt to improve their appearance, many of
which may be unhelpful and, in some cases, potentially
dangerous.
Patients should be asked how romantic partners, family
members, and close friends feel about the decision to change
a physical feature. While these individuals likely influence
patients’ decision-making process, their role may not be as
great as intuitively thought. For example, candidates for
cosmetic breast augmentation surgery reported that their
decision to seek surgery was influenced more by their own
feelings about their appearance than it was influenced by the
thoughts of their romantic partners. Nevertheless, patients
who seek treatment specifically to please a current partner, or
attract a new one, are thought to be less likely to be satisfied
with their postoperative outcomes. Thus, the treatment pro­
vider should inquire about patients’ general expectations
about how the change in appearance, which may be rather
subtle and potentially unnoticed by others, will influence
their lives.
There is some evidence to suggest that individuals who
undergo cosmetic procedures are seen as younger looking
and more attractive. However, there is no evidence to suggest
that aesthetic procedures directly impact interpersonal rela­
tionships. Therefore, patients should be reminded that it is
impossible to predict how others will respond to their changed
appearance. Some patients may find that few people notice
the change in their appearance, while others may have the
experience that everyone seems to notice them. While some
patients may find this attention pleasurable, others may
find it uncomfortable. To assess this issue, patients should
be asked how they anticipate their lives will be different fol­
lowing treatment. The experience of unmet postoperative
the first procedure or if they were satisfied with the outcome
and are now interested in modifying another aspect of their
appearance.
Assessment of psychosocial functioning
prior to cosmetic medical treatment
Physicians who perform cosmetic surgical and minimally
invasive treatments should evaluate and monitor the psycho­
social status and functioning of patients who seek these pro­
cedures. Most patients who present for these treatments are
thought to be psychologically stable. Prospective patients
typically have specific appearance concerns, internal motiva­
tions, and realistic postoperative expectations. Thus, most
patients do not need a psychological evaluation prior to treat­
ment. Nonetheless, a sizable minority of individuals who
present for aesthetic medical procedures may present with a
range of psychiatric conditions – BDD, depression, eating
disorders – that may contraindicate a cosmetic procedure.
In the competitive marketplace of aesthetic medical treat­
ment, where physicians from a range of medical specialties
offer cosmetic procedures, it is unlikely that any physician
currently requires new patients to undergo a mental health
evaluation prior to treatment. Such a practice would likely
drive patients to other practices almost instantaneously. More
importantly, given the lack of reliable evidence suggesting a
relationship between preoperative psychosocial status and
postoperative outcomes (with perhaps the exception of BDD),
recommendations for such routine evaluations is not war­
ranted.20 Rather, physicians who offer aesthetic procedures,
like all medical professionals, should assess and screen for the
presence of psychopathology as part of a medical history and
completion of physical examination. Unfortunately, most
physicians (or their delegates) likely skip this part of the
assessment and, as a result, likely fail to identify patients who
may exhibit symptoms of significant psychopathology or
have a history of abuse or neglect that may impact their
psychosocial functioning.
Specific questions asked during the initial consultation can
be an effective way of identifying patients with mental health
issues. These questions can help safeguard providers against
patients who could become litigious or violent; it also provides
an opportunity to direct patients to appropriate psychiatric
treatment if needed. Patients should be informed that these
questions are part of the practice’s standard initial consulta­
tion procedures and are asked of all prospective patients. Such
a statement can help reassure patients that they are not being
“singled out” and may encourage an honest disclosure of
information.
Psychiatric history and status
The assessment of the patients’ psychiatric history and current
status is a central part of the evaluation. Approximately 20%
of patients who seek cosmetic surgery or minimally invasive
procedures report using a psychiatric medication at the time
of treatment.115,141 As mental health professionals frequently
observe, patients who receive these medications from a
primary care physician often do not experience complete
relief from their symptoms. Thus, a psychopharmacologic

32
CHAPTER 3 • Psychological aspects of cosmetic surgical and minimally invasive treatments
BDD bring drawings to the consultation that detail how they
would like to change their appearance or photos of celebrities
to illustrate their idea of perfection; such behaviors may
indicate the extensive amount of time they spend obsessing
about their appearance. Patients who have had multiple
procedures on the same body part yet still express dissatisfac­
tion with treatment outcomes may have BDD. Those who
have had many previous cosmetic procedures should be care­
fully queried about their satisfaction with the prior procedures,
the nature of their appearance concerns, BDD symptoms, and
expectations for treatment outcomes.
The degree and psychosocial consequences of dissatisfac­
tion also should be assessed. Asking the patient about the
amount of time spent thinking about a feature or the activities
missed or avoided may indicate the degree of distress and
impairment a person is experiencing and may help determine
the presence of BDD. Self-report measures of BDD symptoms,
such as the BDDQ, also may be helpful in this regard.
If the surgeon suspects that a patient has BDD, he/she is
encouraged to inform the patient of their impressions and to
provide some brief education about the disorder (e.g., “It
sounds like you have a body image problem known as body
dysmorphic disorder, a known and treatable condition”). We
also recommend that surgeons inform patients with suspected
BDD that they are concerned that the patient will be dissatis­
fied with the outcome of the surgery and that cosmetic pro­
cedures rarely help BDD symptoms, and can in fact make
them worse. Then, patients should be briefly made aware that
there are effective treatments for BDD, including psychiatric/
psychological treatments, and referrals to a psychiatrist and/
or psychologist can be made. It can be helpful to provide
patients a list of local mental health providers with expertise
in BDD or other body image problems and to convey to the
patient that effective mental health treatments are available.
A major challenge in making such referrals is the poor or
absent insight that is typical of BDD. Patients may resist the
diagnosis because they believe that they truly are ugly. It can
be helpful for surgeons to note that there is a mismatch
between how people with BDD see themselves compared to
how others see them, for reasons that are not well understood
– that individuals with BDD see themselves as ugly or
deformed, whereas other people do not see them this way. It
is not helpful, however, to argue with the patient about how
they look or to try to convince the patient that you are right
and they are wrong, as this is likely to be ineffective. In our
experience, it is more helpful to empathize with and under­
score the patient’s distress and the impact of their appearance
concerns on their daily lives (e.g., “I can see how worried you
are about your jaw and how much it’s upsetting you and
interfering with your life”); this approach can be helpful in
encouraging patients to accept a mental health evaluation and
treatment.
In general, it is best to be clear about why a referral to a
mental health provider is being made (to get effective treat­
ment for BDD) and not to promise that surgery will be per­
formed after the psychiatric evaluation. It is best not to
minimize the patient’s concern (e.g., “It’s all in your head”),
provide reassurance that they look okay (unless the patient
recognizes this to some degree themselves), or say something
like “Well, I see a little something, but it’s not that bad”; these
strategies are unlikely to be helpful and may even exacerbate
the patient’s distress. Surgeons are also discouraged from
expectations is another possible explanation of the relation­
ship between cosmetic breast augmentation and suicide.121
Some women may present for breast augmentation surgery
with unrealistic expectations about the effect that the proce­
dure will have on their romantic relationships or daily func­
tioning. When these expectations are not met, they may
become despondent, depressed, and potentially suicidal.
Physical appearance and body image
Individuals presenting for an aesthetic treatment should be
able to articulate specific concerns about their appearance that
should be visible to the treatment provider with little effort.
Patients who are markedly distressed about slight defects that
are not readily visible may be suffering from BDD. The degree
of emotional distress and impairment, rather than the specific
nature of the defect, may be more accurate indicators of BDD
in aesthetic medical patients.
Aesthetic medical treatment providers, and consulting
mental health professionals, should be prepared to ask specific
questions to assess for the presence of BDD. Individuals with
nonexistent or minimal flaws who spend at least an hour a
day preoccupied with perceived flaws, who experience result­
ing clinically significant distress or impairment in functioning,
and who perform at least one associated repetitive behavior
are believed to have BDD.
Patients who present with concerns about minimal or slight
defects in appearance (e.g., asymmetry that would typically
only be noticeable to a trained professional) should be care­
fully assessed. In cases where patients present with minimal
or slight defects in appearance, the degree of distress they are
reporting and the amount of functional impairment they are
experiencing can help differentiate those with and without
BDD. For example, a patient who is so concerned about a
minimal or slight defect that (s)he refuses to attend school or
leave home likely meets criteria for BDD. In contrast, a patient
with a minimal defect who reports feeling self-conscious in
some situations but is otherwise functioning well most likely
does not have BDD.
Patients with BDD are often secretive about and ashamed
of their concerns and the extent of their preoccupation and
distress. In our experience, some patients purposely minimize
their symptoms in the hope that the surgeon will not discover
that they have BDD and refuse to operate. As discussed above,
it is not uncommon for BDD to go undetected by aesthetic
surgeons or dermatologists who offer cosmetic treatments.
The majority of aesthetic surgeons and dermatological sur­
geons have reported that they have had the experience of
operating on a patient only to recognize, during the postop­
erative course, that the patient had BDD.116,117
There are a number of other behaviors that may suggest
the presence of BDD or other significant psychopathology. In
general, patients should be able to discuss specific appearance
concerns that are readily observable. Patients who present
with vague, nonspecific complaints (e.g., comments about
being ugly or deformed, “my jaw just doesn’t look right”)
may have BDD. Patients who express beliefs that other people
are taking special notice of them because of their appearance
“defect” may have BDD. Other individuals may make
repeated requests for reassurance about the perceived flaw,
which may signal the presence of BDD. Some patients with

33
Conclusion
anger and defensiveness, believing that they will only feel
better if they look better. Others may assume that the medical
professional assumes they are “crazy”. Many will likely refuse
to go to the consultation, which can provide indirect, confir­
matory evidence that a patient is not psychologically appro­
priate for surgery. To increase the likelihood that the patient
will accept the referral, it should be treated like a referral to
any other health professional. The patient should be informed
of the specific areas of concern and the reason for the referral.
This information also should be shared with the mental health
professional in advance of the consultation.
Conclusion
Interest in the psychological aspects of cosmetic medical
procedures has grown in parallel to the overall popularity of
the treatments. While early clinical reports from this literature
suggested that most patients presented for treatment with
some form of psychopathology, more contemporary and
methodologically rigorous studies have identified few differ­
ences between individuals who seek cosmetic treatments and
those who do not. Perhaps the most consistent difference is
that those women and men who seek cosmetic treatments
report higher levels of body image dissatisfaction. This dis­
satisfaction is believed to motivate the pursuit of treatment
and improve following improvements in appearance.
Unfortunately, some individuals present for cosmetic treat­
ment with extreme body image dissatisfaction. This dissatis­
faction is a hallmark characteristic of both eating disorders as
well as body dysmorphic disorder. Between 5% and 15% of
persons who seek cosmetic treatments are believed to suffer
with BDD; unfortunately, few experience improvements in
their symptoms following treatment, leading to the belief that
BDD is a likely contraindication to cosmetic treatment.
For these and other reasons, plastic surgeons and other
physicians who offer cosmetic treatments are encouraged to
evaluate the psychosocial functioning and status of new
patients. Assessment of motivations and expectations for
treatment, body image and appearance concerns, as well as
psychosocial status and history can identify patients who may
be inappropriate for treatment. Such assessment can also help
to insure that the largest number of patients experience their
physical as well as psychosocial goals for treatment.
giving in to requests to perform minor procedures or to offer
less invasive treatment options to appease the patient,30 as in
our experience patients may have a poor outcome following
even minor interventions. Referrals to other surgeons are also
discouraged, as this gives patients the implicit message that
surgery may be helpful when in fact it appears unlikely to be.
Observing office behavior
Physicians and their staff should pay attention to patients’
behavior in the office. Deviations from expected, typical
behavior may reveal clues about BDD or other psychopathol­
ogy. Demands for unusual appointment times (e.g., in the
evening or early morning), repeated cancelling and reschedul­
ing of appointments, excessive phone calls, angry or threaten­
ing demands to speak with the surgeon, or repeated
reassurance-seeking from staff about their appearance may be
indicative of BDD. Surgeons may be unaware of these behav­
iors, particularly if patients are “on their best behavior”
during their consultation in hopes of convincing the surgeon
to perform the desired procedure. Surgeons can consider
asking patients to return for a follow-up consultation if the
office staff raise concerns. A mental health evaluation is rec­
ommended if concerns about the patient’s behavior persist.
General considerations
A mental health professional can be a valuable consultant to
an aesthetic medicine practice. The mental health professional
should have a good understanding of the psychological
aspects of aesthetic medicine, as well as knowledge of disor­
ders with a body image component, such as BDD and eating
disorders. In most cases, the mental health professional will
be called upon to assess a patient’s psychological appropriate­
ness prior to and for a given procedure. The mental health
professional also may be asked to consult on the care of a
patient postoperatively. This is most likely to occur in situa­
tions where the patient is dissatisfied with an objectively
successful outcome or when the patient experiences a signifi­
cant postoperative complication and is experiencing emotional
distress.
Regardless of the circumstances, aesthetic surgery patients
may react to a referral to a mental health professional with
57. Phillips KA, Menard W, Fay C, Weisberg R. Demographic
characteristics, phenomenology, comorbidity, and family history in
200 individuals with body dysmorphic disorder. Psychosomatics.
2005;46:317–325. A review of the demographics of body dysmorphic
disorder. Of particular note is the finding that 20% of patients with
BDD have a first-degree relative that is similarly affected. When
compared with a 5 to 10% parallel prevalence in breast cancer, it is a
strikingly important observation.
89. Didie E, Tortolani CC, Pope CG, et al. Childhood abuse and
neglect in body dysmorphic disorder. Child Abuse Negl.
2006;30:1105. To my knowledge, the first paper establishing a history of
childhood abuse or neglect in a group of body dysmorphic disorder
patients. This was the primary missing link.
92. Constantian MB, Lin CP. Why some patients are unhappy, part
two: relationship of nasal shape and trauma history to surgical
success. Plast Reconstr Surg. 2014;134:836–851. In this paper and part
one with the same title analyzing data from 100 consecutive secondary
rhinoplasty patients, my co-author and I established a positive correlation
between the degree of nasal deformity, the history of childhood abuse or
neglect, the number of prior rhinoplasties, the number of other cosmetic
surgeries, and satisfaction with the surgical outcome. Patients who
originally had noses that they knew were normal but had surgery
anyway (which defines body dysmorphic disorder) had also undergone
the most rhinoplasties, the most other cosmetic surgeries, were the least
likely to be satisfied with one corrective operation (in this series, 3%),
and had the highest prevalence of childhood trauma (over 90%).
94. McFarlane AC, De Girolamo G. The nature of traumatic stressors.
In: van der Kolk B, McFarlane AC, Weisaeth L, eds. Traumatic
Stress. New York: Guilford Press; 2007:129–155. This chapter from
van der Kolk’s first landmark book details the effects of trauma upon
Access the complete reference list online at

34
CHAPTER 3 • Psychological aspects of cosmetic surgical and minimally invasive treatments
brain development, function, and memory. In doing so, it provides
insight to the seemingly irrational behavior of surgeons’ most unhappy
patients, who are responding to triggers unappreciated by the surgeon.
99. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood
abuse and household dysfunction to many of the leading causes of
death in adults. Am J Prev Med. 1998;14:245–258. In one of many
papers generated by the Kaiser Permanente/CDC study of more than
17 000 patients, the authors not only document the surprisingly high
prevalence of childhood trauma, but also its direct correlation with the
most common illnesses and causes of death in adults.
108. Rausch SL, Phillips KA, Makris N, et al. A preliminary
morphometric magnetic resonance imaging study of regional brain
volumes in body dysmorphic disorder. Psychiatry Res. 2003;20:13–
19. Another piece of the puzzle: evidence that the “trauma circuit”
(limbic system, thalamus, amygdala) light up in body dysmorphic
patients precisely as they do in traumatized patients or those with PTSD.

34.e1
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113. Sarwer DB, Brown GK, Evans DL. Cosmetic breast augmentation
and suicide: a review of the literature. Am J Psychiatry.
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114. McLaughlin JK, Wise TN, Lipworth L. Increased risk of suicide
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115. Brinton LA, Brown SL, Colton T, et al. Characteristics of a
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seeking other types of plastic surgery. Plast Reconstr Surg.
2000;105:919–927.
116. Cook LS, Daling JR, Voigt LF, et al. Characteristics of women
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119. Murphy DK, Beckstrand M, Sarwer DB. A prospective, multi-
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122. Schlebusch L, Mahrt I. Long-term psychological sequelae of
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4 
The role of ethics in plastic surgery
Phillip C. Haeck
SYNOPSIS
■ Ethics as seen by professional associations.
■ Ethical relationships with patients.
■ The ethics of advertising.
■ The role of ethics in the outpatient office.
■ Ethics in the operating room.
■ Ethical relations with other providers and third-party payers.
■ The ethics of expert witness testimony.
■ Summary.
The subject of ethics pervades the specialty of plastic surgery.
Ethical decisions are highly prevalent in its practitioners yet
few realize they confront these choices regularly, almost
daily. Behaving in a morally responsible fashion, maintain­
ing high personal codes of conduct, and remaining compe­
tent in operations are noncognitive functions for the vast
majority of surgeons; it is deeply ingrained in the psyche. It
also serves the surgeon well in presenting an overall highly
regarded and deserved reputation amongst colleagues and
the public.
Who to operate on and, more importantly, who not to
operate on can in many instances be dilemmas that require
moral choices. But many times the rationale is played out in
the surgeon’s subconscious, one more decision out of dozens
made daily, with just a few moments to evaluate the alterna­
tives. Plastic surgeons do not go home to their spouses every
night and claim they made a number of highly ethical choices
that day. Yet in reality the effects of not making the right
choices can set up traps and entanglements. Breaching unwrit­
ten and written moral codes may bring consequences in this
specialty. The harm may be done to others. The fallout is
usually the surgeon’s predicament.
Consider this common scenario. A patient consults the
plastic surgeon for a rhinoplasty, complaining of poor breath­
ing and an old fracture. She also doesn’t like the shape of the
tip of her nose. She claims she has no money for any private
payment of the fees involved. But she also claims to have over
a half-dozen friends who want their noses changed and states
she will take them to meet the surgeon on each of her subse­
quent visits. The surgeon agrees to charge her insurance
company for the entire procedure, hoping in the end to capture
more business from the friendly and social patient, deciding
it is a justifiable prevarication. Is this an ethical dilemma?
The moral issues of this story become a web of further
entanglement when the insurance company suspects it paid
for a portion of the surgery that was cosmetic and not func­
tional. A few months later the patient receives a denial of
payment from the company for what they have determined
is the cosmetic portion of her anesthesia charges, the facility
fee and surgeon’s fees. She is suddenly required to pay a
sizable amount of money and in turn begs the surgeon to
write off the balance since she still cannot afford to make up
the difference.
Did the surgeon commit fraud? Was his decision to further
his practice by committing a deception immoral? If he
refuses to let the patient off the hook financially, will this
affect his reputation with her friends who are by now signing
up for their own surgery? Even if he made the very first
decision that led to this predicament casually he cannot
easily make this last choice without some degree of moral
calculation.
Consider another situation. A 65-year-old uninsured dia­
betic is hit by a bus and suffers a compound tibia–fibula
fracture and degloving injury of one-third of his lower leg. He
is a smoker and is insulin-dependent. After the fracture is
stabilized the plastic surgeon is asked to consult on the case
for soft-tissue coverage of the sizable defect. Knowing that the
zone of crush injury is extensive and there is compromised
blood flow to the lower leg, the surgeon must decide if a
long and expensive operation with a modest but very real
chance of being unsuccessful is worth the effort and cost. With
an amputation below the knee the chances this man will
ambulate in a prosthesis are good, but not guaranteed. Will

36
CHAPTER 4 • The role of ethics in plastic surgery
Ethics as seen by professional
associations
The American Society of Plastic Surgeons (ASPS), the largest
membership organization in the specialty, was formed in
1935. The association’s attempt at a written Code of Ethics
was first published in 1980. Members in good standing are
expected to be familiar with this code and to adhere in their
daily practice of surgery to the standards espoused within it.
Failure to adhere to the guidelines can result in disciplinary
action, including expulsion.
The expectations for ethical behavior on the part of members
of the professional association are strongly worded and very
specific. At times the code has been modified to meet new
challenges such as those posed by the internet, charity raffles,
and expert witness testimony. All realms of the specialty are
covered within its dictums. The code also clearly spells out
how a member will be dealt with if there is perceived to be a
violation of the rules of the code.
Other members, patients, and lay persons can all lodge a
written or verbal complaint with the ASPS Ethics Committee,
stating what they think may be unethical behavior on the part
of the member, actions that fall outside the proscriptions of
the code. The member is then investigated by his or her peers
and if it is decided that a violation did take place, the informa­
tion is then passed along to the Judicial Council. The Council,
comprised of members voted into that position, holds hear­
ings to determine if sanctions should be placed on the member.
Personal appearances before the Council are welcomed and
the decisions made after a hearing are binding. Appeals of
these decisions can be made to the Board of Trustees of the
organization but are done infrequently. Plastic surgeons who
are members of the American Society of Aesthetic Plastic
Surgery (ASAPS) are subject to the same Code of Ethics and
discipline. Members in good standing of both organizations
may be elected to hold positions on the Ethics Committee and
the Judicial Council for a period of 2–3 years.
Table 4.1 is a compilation of the data available from a
review of the ASPS Ethics Committee’s activities over the 4
years from 2006 to 2009.
While fewer complaints have been lodged lately, down to
81 in 2009 from 139 in 2006, the number of complaints that are
reviewed after a committee investigation remained stable
over this same period. Likewise the number of reviews that
led to a hearing stayed at the same level, as did the number
of hearings that resulted in disciplinary action.
prolonged recovery from a valiant limb salvage operation be
the better choice? The surgeon knows he will not be reim­
bursed well for his efforts. His decision, if made on high
standards, is based on what is right for the patient, not the
surgeon.
These types of choices are encountered in similar situa­
tions on a daily basis by plastic surgeons all over the country.
How one deals with these types of scenarios is multifacto­
rial, complex and requires sophisticated decision trees. It is
not immoral or unethical to say no in these situations.
Highly ethical persons have a well-developed internal
moral code. They conduct themselves accordingly and believe
that to do anything less would make them guilty of immoral­
ity. Contrast this with a sociopath who has no capacity for
guilt, makes choices that he knows will deliberately harm
others and then denies responsibility for the consequences.
People living at the opposite extremes of this spectrum are
rare. Most of us fall somewhere in between, the angel on one
shoulder and the devil on the other.
Surgeons are themselves no different even though they
have all supposedly taken the oath of Hippocrates to “above
all else, do no harm”. The training of surgeons results in
behavior that is consistent with the moral character of the role
models the surgeon learned from, in both a positive effect and
a negative one, sometimes full of awe, other times full of
loathing. The behavioral end result of this training is a hybrid
of choices, instincts, and internal codes that is rarely mono­
lithic. More often the surgeon who has trained hard for a
subspecialty designation is a complex, principled individual
with a great capacity for a wide variety of mostly predictable
and virtuous behaviors.
The specialty of medical ethics comprises a wide range of
subjects that is considered valuable for physicians to consider
and be knowledgeable about. It also takes into account the
effects surgeons can have on society and vice versa. This
includes controversial issues such as whether or not society
should allow late-term abortions, death with dignity, or
rationing of expensive treatments, to name a few. In general,
the literature in medical ethics contains very little on the
subject of plastic surgery.
In the lay literature, the ethics of having one’s appearance
altered is a somewhat more common, but still rare, subject.
Feminists weigh in on this topic most frequently, as do
PhD candidates in the fields of sociology and behavioral
psychology.1–3 Yet these dialogues do not take into account the
possibility that the surgeon has high moral standing. Instead
the plastic surgeon is cast as a villain, forcing his or her sus­
ceptible patients into paying more than they can afford for
quite frivolous reasons. The patients are defined as foolishly
chasing an impossible-to-obtain god-like appearance, invol­
untary victims of society’s fascination with attractiveness. A
further subtheme of these publications is the speculation that
widespread alteration of homely persons into attractive ones
will in the long term breed out common sense in our society.
The specialty journals in reconstructive or cosmetic surgery
rarely, if ever, contain purely ethical articles of interest to the
plastic surgeon.4–6 There are, for now, no ethical courses one
can take at medical symposia, and forums on the subject of
ethical plastic surgery are unheard of.
Yet the fact remains that ethical decisions are quite common
in the lives of plastic surgeons, in some cases occurring even
on a daily basis.
Table 4.1  American Society of Plastic Surgeons Ethics
Committee’s activities, 2006–2009
Ethics complaints
2006
2007
2008
2009
New complaints
139
131
114
81
Complaints dismissed
101
77
54
36
Cases reviewed
38
54
60
45
Referred to Judicial
Council
10
15
18
15
Cases disciplined
5
9
8
8
Complaints closed
153
129
108
84

37
Ethical relationships with patients
Table 4.2  Average complaints by category per year, 2006–2009
Advertising
50
Medical board discipline
20
Contest
11
Standard of care
12
Expert witness testimony
10
Professional misconduct
6
Exorbitant fees
3
Criminal charges
2
Expert report
2
Total
116
Table 4.2 reveals the average number of complaints by
category over the 4-year average. Advertising interpreted to
violate the Code of Ethics has remained the complaint with
the highest frequency over many years. The second highest
category remains the investigation of those members who
have been sanctioned by their state medical boards. The third
category, unethical behavior while participating in a contest
where the prize is free surgery, remains controversial. Some
members feel that promoting themselves over nonmembers
who are self-designated cosmetic surgeons is necessary to
compete for potential patients and that this portion of the
code is too restrictive. Still others feel it adequately reduces
the number of violations of the code and reduces behavior
that besmirches the reputation of all plastic surgeons. This
controversy is unlikely to end soon.
Plastic surgeons overall have a highly visible position in
the medical profession. Reactions to unethical behavior can
thus be intense and scathing. For this reason members of the
ASPS and ASAPS are reminded from time to time to review
their Code of Ethics. While the vast majority of members will
never in their careers be accused of violating it, pleading that
you had no idea your actions were directly opposed to the
body of rules for conduct in the code never works well as a
defense when confronted by this system.
Ethical relationships with patients
In an ideal world plastic surgeons would only meet patients
for consultations that were precisely matched to their skills,
with the perfect indications for only the operations they pre­
ferred to perform. The surgeon would immediately compre­
hend the correct desires of the patient, infallibly interpreting
that person’s own unique ability to deal with a complication
or a less than desirable result. The surgical results would
always heal immediately with no complications. The adoring
patient would then refer many more patients just like
themselves.
In reality things are rarely clear and perfect. Patients fret
about what they will look like after cosmetic surgery; they
worry hopelessly before reconstructive surgery that they will
still end up looking deformed and disfigured. They fritter
away the surgeon’s time with endless questions about whether
or not they should have the surgery. Then they present impos­
sible impediments to surgery scheduling and are often unre­
alistic about their recovery, postoperative pain, and activity
restrictions. In a busy, demanding practice, how surgeons take
control of these situations, occasionally to their own advan­
tage, can sometimes lead to unethical decision-making. Taking
the high moral ground, while always the best choice, can
sometimes seem impractical and intrusive when demands on
the surgeon are almost overwhelming.
When a surgeon’s compensation is determined solely by
the number of surgeries he or she can perform in a week, a
month and a year, operating on a person ill-suited to the
surgery can possibly, perhaps eventually, occur. Some sur­
geons claim only to operate on patients with whom they feel
comfortable. Obviously they have the luxury of dismissing
patients they don’t like and have a practice of truly elective
procedures only. Being financially rewarded from performing
surgery on people with unrealistic expectations, who may be
ill-suited emotionally for the end result, is not the norm in this
specialty. Yet it does occur, perhaps too often.
The consequences of this, an upset patient who abhors the
result and threatens lawsuits or reports to the media, will in
most cases lead to regret, the surgeon ruing the day he or she
laid the scalpel to that person’s skin. But it does not necessar­
ily guarantee the surgeon has learned to be more careful from
the experience.
In the training of plastic surgeons, being grilled over and
over from the elder surgeon as to the correct indications for
surgery is common. The master surgeon feels he or she is there
to teach future surgeons the unwritten rules, the pitfalls of
making the wrong choice, and the integrity required to
succeed in the specialty. Once in practice, however, new sur­
geons no longer have to answer for their every action. The
guidance for making the right, not the wrong, choice is up to
them alone, and the consequences can lead to an unhappy
patient, a profound effect on their reputation, disciplinary
action or, most unfortunately, malpractice litigation.
So it is that surgeons are ultimately judged by the “standard
of care”, what a reasonably prudent surgeon would do with
similar training in similar circumstances. Moral and ethical
behavior is one facet of the standard of care.
Truly ethical surgeons choose their patients based on a
thorough evaluation that includes many factors, compensa­
tion being the least important. Patients with unrealistic
expectations or obsessive behavior are dismissed appropri­
ately. Patients who need reconstruction are chosen on the
surgeon’s ability to match the correct operation to the problem.
Patients with needs beyond the surgeon’s own particular
skills are referred to others who have more expertise in
that area.
Society expects that conventional and virtuous surgeons
spend time teaching their patients what their expectations
should be both for the less-than-perfect result and for unfor­
tunate but rare complications. The option to dismiss the
surgeon or seek another one once patients know the risks and
alternative treatments should always be allowed. This is
accompanied by a disclosure of how much financial respon­
sibility the patient must bear for reoperations when things do
not go as planned and another operation is needed.
In reconstructive surgery, patients’ ability to pay or the type
of insurance coverage they have does not affect the ethical
surgeon’s decisions to operate. The complete lack of insurance
is balanced by the ability to find some type of payment cover­
age through social services or simply accept a very reduced
fee in exchange. The need for the operation should not be

38
CHAPTER 4 • The role of ethics in plastic surgery
abound that make this an easy task. Any altering of before-
and-after photos is considered by the ASPS ethics process to
be false and misleading advertising, subject to sanctions.
Other behaviors considered to be unethical include the
trading of surgery quid pro quo for media exposure in a high-
profile person. Examples unfortunately exist of television
figures such as news reporters undergoing surgical treatment
in return for free testimonials about the surgeon, on air or at
public appearances. While the media industry doesn’t con­
sider this out of the ordinary, plastic surgery associations
maintain that it is in fact unethical.
altered by the compensation that will result, especially if it is
little to nothing at all.
The ethics of advertising
Advertising was considered completely unethical for plastic
surgeons well into the 1980s. A few who tried it were consid­
ered outlaws and often expelled from their national or state
and local plastic surgery associations. Many felt it “cheapened
the specialty” and that reputation was all that should be
needed to attract more patients.
Along came the 1990s and the social attitudes of the spe­
cialty changed. Television discovered plastic surgery and
shows like Extreme Makeover thrust plastic surgery into the
homes of millions, making “mommy makeovers” a household
word. But it was the internet that tore down the last bit of
reluctance to make promotion a major part of the everyday
practice of plastic surgery.
Advertising in the specialty, when done in good taste and
without hyperbole, will now be around for a long time.
Unfortunately unethical advertising, done in poor taste with
mind-numbing self-promotion, is also here to stay (Fig. 4.1).
The ASPS Code of Ethics has been modified several times
in the last dozen years to keep up with the changing relaxation
of social mores to physician advertising. But complaints from
members about other surgeons’ unethical promotions con­
tinue to rank as the most frequent complaints each year to the
ASPS Ethics Committee (see Table 4.2).
Examples abound. Fig. 4.2 is exactly what the Code of
Ethics was meant to prevent: a rather tacky approach that
cheapens and sullies the specialty regardless of the origin. The
public lumps all plastic surgeons into one category, whether
they are Board-certified or self-designated.
Showing misleading before-and-after photos, then imply­
ing this to be a typical result that can be obtained by any
patient, is considered unethical as well (see Fig. 4.2). In addi­
tion, the temptation to airbrush imperfections or scars out of
the photos can be hard to resist when software applications
Fig. 4.1  Unethical advertising – billboard photo: “two for
one.”
Fig. 4.2  Unethical advertising where a single image is used for both before and
after figures through the magic of digital alterations.

39
Ethical relations with other providers and third-party payers
Ethics in the operating room
The outcomes of any surgery depend on the correct applica­
tion of principles, decisions, and treatments, all of which
require multiple informed and decent choices. How the
surgeon conducts himself, resisting the temptation to blame
others and even the instruments when things do not go as
planned, affects his reputation amongst staff and colleagues.
Each correct or incorrect decision made during surgery can be
a reflection of the character and mores of each surgeon.
Cutting corners for economic reasons, covering up mis­
takes, and delivering different outcomes than planned may be
fundamental indications of a dishonest character. Surgery is
not immune to the effects of personality flaws.
The analogy of the old fairy tale by Hans Christian Ander­
son, The Emperor’s New Clothes, to the potential for deceitful
behavior occasionally exhibited by plastic surgeons can be
illustrative. In the story, the weaver promises to make the
emperor a set of clothes invisible to those ignorant or unfit for
their positions, completely fooling him into wearing nothing.
It is a classic case of “mind over matter”.
To the extent this can be applied to plastic surgery, the
limited effects of some surgery may depend on the extent to
which the surgeon built up the patient’s expectations, knowing
full well that the patient had paid for something possibly
requiring more time and effort or that might have had a more
clearly effective result. While this is rarely as brazen as in the
old fairy tale, it can slip into various parts of surgery, espe­
cially with the more common use of treatment machines the
patients know little about. The happiness of the patient
depends on the expectations for beauty woven into the sales
presentation by the surgeon. Results will vary of course.
Certain energy-dependent skin treatments whose effects
take many months to be appreciated parallel this story. Is it
dishonest to promise fewer wrinkles when it is known the
effects won’t be as plainly evident as other treatments or as a
more expensive surgery? When the frequently pricey pay­
ments on the machine need to be met, the temptation to
oversell it can be enormous. The ethical dilemma is not
just to sign reluctant patients up but also then to deny that
the outcome was less effective and did not meet their
expectations.
Conventionally moral surgeons recognize this trap and
avoid it, choosing to defer income for traditional effectiveness.
Others, who might still consider themselves to have main­
stream values, nonchalantly overlook the issues for the sake
of keeping busy, building their reputation and impressing
other surgeons with the size of the practice. Willful and
malevolent deception may not be in the forefront; mostly it is
hidden, buried in this specialty behind layers of complex situ­
ations. But it certainly exists in many forms.
Ethical relations with other providers
and third-party payers
The ASPS Code of Ethics is very specific about the pitfalls in
monetary relationships that can exist in referral networks.
Brazen kickbacks for referring a patient for whom the surgeon
will be rewarded financially are considered illegal in most
states. Fee splitting is as well. With Medicare it can become a
The role of ethics in the
outpatient office
Building and maintaining relationships with patients and
staff can occupy a good deal of the plastic surgeon’s time. The
temptation to extend those relationships outside the office or
the practice and outside a professional nature will always be
present. Grateful patients wish to offer favors in exchange for
their surgeon’s success. Adoring staff members want to know
more about what their boss is like outside the clinic. It is only
natural for attractions such as these to take place. How the
surgeon handles this can make him or her more successful,
but can also lead to situations that can become unconven­
tional, complicated, and entangling.
While it is not considered unethical to socialize with one’s
staff, establishing sexual relationships with staff and patients
violates general standards for professional conduct, and can
end with unfortunate consequences, including charges of
sexual harassment or other civil charges. Lecherous behavior,
physical advances, and the creation of a sexually harassing
environment are grounds for dismissal from professional
organizations, civil lawsuits, and can even at times be consid­
ered criminal in nature.
Conventional behavior sets limits on these situations. But
the unique situation in plastic surgery, where the female
patient may be both physically and emotionally exposed, can
create powerful forces that test the limits of decency, honesty,
and virtue in male plastic surgeons. To a lesser extent the
opposite gender roles can also occur, as women are becoming
plastic surgeons at record rates.
Personal standards of conduct vary tremendously in the
specialty, but television shows depicting sleazy, illegal, and
unconventional behavior by plastic surgeons may have some
element of truth. The malevolent, licentious, and perverse
personality in some surgeons may in fact be portrayed in
these situations. Hopefully this will remain rare and only in
the purview of television. Brazen behavior may eventually be
reported to some type of authority. The potential personal
damage that can be done in these situations by and to sur­
geons should be deplorable to all.
Attorneys experienced with workplace lawsuits always
recommend that, if a romantic relationship develops between
a patient and a single physician, the patient must be given
the choice of terminating either the doctor–patient relation­
ship or the personal relationship. If the first choice is made
the patient should submit to being discharged from the
surgeon’s care to another physician. Likewise, if a romantic
relationship arises with staff members it is considered ethical
and wise to discontinue the employee–employer relationship
immediately, though the evidence suggests this happens
infrequently.
The plastic surgery practice with multiple physicians pre­
sents the possibility for competitive economic and unprofes­
sional behaviors amongst surgeons and staff. Manipulation
of the staff to hinder the success of partners or to direct
more business to oneself is considered unethical. Hiding
income from expense-sharing agreements, contributing to
rumors and lies about other partners, and other obtrusive and
malevolent behaviors towards them ignore the rules of
decency and virtue.

40
CHAPTER 4 • The role of ethics in plastic surgery
Condemning one way or the other as not in alignment with
accepted principles when in fact it may very well be, can
swing the jury or judge to rule against the other member.
Regardless of the outcome the member who has a legitimate
issue can submit the testimony he or she feels was false or
misleading to the ASPS Ethics Committee who will review the
situation and arrive at a conclusion.
The Code of Ethics is also very specific about the expert’s
reasonable experience with the surgery that was performed.
The phrase “recent and substantial experience” needed to be
more carefully defined because of retired surgeons’ declara­
tions of the standard of care when in fact they may have not
performed any surgery, let alone the one in question, for over
a decade. As the code is written now this means within the
last 3 years. Testifying about a procedure the surgeon has not
performed then in 4 or more years can be considered mislead­
ing testimony.
Overall, these issues became such frequent complaints that
multiple other modifications to the Code sections on testify­
ing have had to be made. This now includes a declaration that
all experts may be asked to sign, certifying they will be truth­
ful in their testimony. The submission of the signed statement
is voluntary but can be used as evidence in the courtroom,
especially when a plaintiff’s expert is another member of the
ASPS and has been known to have made misleading state­
ments in other trials.
The ethics of physical or
chemical impairment
As surgeons age they need to maintain both their mental and
physical health. When hand–eye coordination changes with
health and age, who is to judge the standards for ethical
patient care when results are substandard due to unmanaged
tremors, slipping dexterity, declining eyesight and weakened
coordination among other physical effects of aging? Most
surgeons can recall a mentor or friend who carried on despite
these subtle changes who perhaps should have heard the call
to stop operating before it became an issue with detrimental
results. Similarly, however, many can recall a mentor who
carried on with no changes to his or her surgical skills well
into their ninth decade.
Choudry7 did a systematic review of 62 studies that related
medical knowledge and healthcare quality to years in practice
and physician age. Some 52% of these showed decreasing
performance with increasing years in practice for all outcomes
assessed.
Institutions vary greatly in their standards for the aging
surgeon, but when much of plastic surgery is carried out in
one’s own office, there is little to no oversight or governing
body to control these issues.
The demands of plastic surgery where tolerances for error
are measured in millimeters cannot be compared to, say, one’s
driving skills or golf game. Only when one becomes a danger
to others on the road or the course will these freedoms be
taken away.
So the ethics of aging and carrying on beyond a reasonable
time to retire can become acute when others know the truth.
Plastic surgeons who are truly ethical will always question
their results, their ability to learn and grow and their own
quality of care. Warning signs that these questions are not
federal offense. More subtle alignments and quid pro quos with
the referring physician may not constitute civil violations but
nonetheless should be considered carefully as a possible
ethical violation before being carried out.
Correctly applying Current Procedural Terminology codes
which accurately and adequately depict the procedure that
was performed is presumed to be the norm in surgery. Yet
constant tension with third-party payers over what can be
interpreted as their unjustified decreased reimbursement for
procedures requiring high levels of skills creates a negative
attitude that can pervade the business side of the profession.
When it is assumed the insurance company “cheated” the
surgeon on the last payment, the temptation to overbill the
next procedure is difficult to resist. Is it justifiable to “unbun­
dle” codes, upcode, and overbill when one knows that the
insurance company has the upper hand anyway? Who is
really harmed by this? It is situational ethics in play: the
seemingly acceptable deception that is justified because
everyone else, including the payers, is playing the same game.
Much has transpired over the past 5 years as several large
insurance companies have been taken to court in class-action
lawsuits for unlawful changes to the billings of physicians.
Their reply is that fraudulent surgical billing is rampant and
they have to protect their bottom line. The truth may lie
somewhere in between. Nevertheless, the real world seems to
forgive physicians tempted to push the envelope of honor and
conduct for now, given the intense fiscal realities. Patients
may abhor what they hear about hospital billing, but forgive
their own surgeon if he seems honest and caring. The more
personal this becomes, the less patients consider it greed if it
seems to be in favor of a surgeon who did a successful proce­
dure on them.
On the other hand, in university teaching hospitals, where
an attending surgeon is expected to supervise the training of
many residents, there were in the past submissions of sur­
geon’s fees for being in two places at once, or even not present
at all. The explanation was that as a teaching surgeon the
physician was ultimately responsible for all of the outcomes
and therefore justified in receiving the compensation. Some
well-publicized record fines from the Centers for Medicare
and Medicaid in the last decade have led to very strict rules
for supervision and billing. Unethical billing is now scruti­
nized more closely than ever and the plastic surgery team
may not be an exception. Obtrusive rules may have con­
strained the system and possibly gone beyond reason. Unfor­
tunately they now exist because of the past abuse of the
system by a very few.
The ethics of expert witness testimony
As in other sections of this chapter, once again, the issues
outlined in the ASPS Code of Ethics are applicable here as
well. Usually one of the most frequent complaints brought
against a surgeon by another member of the ASPS is for tes­
tifying either in deposition or at trial in a manner that can
mislead the jury or simply be out and out contrived of false
statements of fact. Many of these complaints center around
the expert declaring that the standard of care was to do the
surgery in a specific fashion. In fact, however, many surgeons
may not adhere to those same principles and perform the
surgery differently, but not necessarily outside the standard.

41
Summary
lives of plastic surgeons depends on their background,
training, personal mores, and interpersonal skills. Unethical
behavior can range from pushing the envelope in insurance
coding and billing, all the way to fraud, sexual deviation, and
the cover-up of surgical misadventures. It is a pervasive issue
that can be seen as either business as usual or a moral stance
always to behave ethically. Human nature being what it is, the
give and play between highly ethical behaviors and the
alternative will always be a part of the specialty.
References
1. Goering S. The ethics of making the body beautiful. Lessons for
cosmetic surgery for a future of cosmetic genetics. Centre Study Ethics
Soc. 2001;13:20. The author uses a discussion of the ethics of cosmetic
surgery to broach the less familiar territory of potential ethical dilemmas
surrounding “cosmetic genetics”. If a practice used to enhance one’s own
self-image reinforces negative conceptions of normality, this practice is
discouraged.
2. Miller FG, Brody H, Chung KC. Cosmetic surgery and the internal
mandate. Cambridge Q Health Ethics. 2000;9:353–364. The “internal
morality” of medicine is described as the physician’s duty to adhere to
certain clinical virtues. The ethics of cosmetic surgery are discussed in this
context.
3. Scott K. Cheating Darwin: the genetic and ethical implications of
vanity and cosmetic plastic surgery. J Evol Technol. 2009;20:1–8. This
paper describes the ethics of cosmetic surgery in the context of evolution.
The argument is advanced that cosmetic surgery uncouples the phenotype
and its role in attracting a mate from the genotype, and may therefore have
ethical implications.
4. Constantian MB. The confusing ethics of mismanaged care. Ann Plast
Surg. 1995;35:222–223. This essay begins with a vignette in which the
author, a plastic surgeon, is asked to determine whether certain procedures
are “cosmetic” or “reconstructive”. What follows is a deft discussion of the
difficult position modern physicians find themselves in when asked to
participate in resource allocation.
5. Krizek T. Surgical error: Ethical issues of adverse events. Arch Surg.
2000;135:1359–1366. This paper addresses the ethical questions
surrounding adverse events. Specifically, issues inhibiting efforts to reduce
the frequency of such occurrences are discussed.
6. Reisman NR. Ethics, legal issues, and consent for fillers. Clin Plast
Surg. 2006;33:505–570.
7. Choudry NK, Fletcher RH, Soumerai SB. Systematic review: the
relationship between clinical experience and quality of health care.
Ann Intern Med. 2005;142:260–273.
8. Oreskovich MR, et al. The prevalence of substance use disorders in
American Physicians. Am J Addict. 2015;24:30–38.
being dealt with truthfully or that the surgeon may need a
reality check include increasing complications, decreasing
patient satisfaction with their results of surgery and mounting
malpractice cases in addition to all of the above.
Beyond that is the issue of the silent colleague who is
witness to incompetent surgery or impairment. For surgeons
there has always been the fear that “turning someone in”,
especially someone who was at one time highly skilled, will
result at some point in recriminations from other surgeons in
the hospital for doing so, either overtly or more often covertly.
Walking the thin line between wishing to act on an errant
surgeon but finding such action too unsavory does no one any
good. Alternatives, however, exist to this onerous task and the
hospital itself is morally responsible to act, with channels for
privilege restrictions being commonly used.
The specialty, however, frequently operates well outside
of the discipline provided by hospital privileges, especially
when one owns their own surgical suite and is subject to no
higher authority. Sadly, then, the end of an era in some sur­
geons’ career has come when malpractice issues pile up and
obtaining insurance becomes too costly to continue or even
nonavailable. Why wait until this tragedy occurs?
Chemically impaired physicians exist in this specialty as
well, since we often are second only to anesthesiologists in
terms of access to narcotics, benzodiazepines and other such
abused medications. The impaired surgeon typically has gone
to great lengths to protect their covert use of both drugs and
alcohol from colleagues; even those closest to the impaired
surgeon in the same practice relationship are usually unaware
of the extent of the problem. Respondents to a recent AMA
study8 met diagnostic criteria for impairment at the rate of
12.9% of male physicians and 21.4% of female physicians.
What therefore is ethical for the plastic surgeon who finds
out the truth about a colleague but has a sense that acting on
it will cause more harm than good? Moral principles must
then override all other consequences, financial resources and
friendships.
When patient care is compromised by impairment we all
have the duty to intervene whether we find it distasteful or
frightening. Avoiding the truth is just as unethical as the act
itself of abusing substances that are too readily available.
Summary
The practice of medicine is complex, requiring constant deci­
sions, discussions, and testing. How this plays out in the daily

5 
Business principles for plastic surgeons
C. Scott Hultman
SYNOPSIS
■ This chapter provides a broad overview of the essential principles that
characterize what a business does and how a business does its work.
■ The ability to apply business concepts is of paramount importance if
plastic surgeons are to become and remain leaders in healthcare.
■ Plastic surgeons should understand and use strategy, accounting,
finance, economics, marketing, and operations to help guide decisions
about their practice.
■ Innovation, entrepreneurship, and human resource management are
three areas where plastic surgeons can add value to their practice and
distinguish themselves from their competition.
Introduction
“Make everything as simple as possible, but not simpler.”
Albert Einstein
Not only is healthcare business, it is big business.
The healthcare–industrial complex incorporates multiple
sectors to deliver health and depends on an expanding group
of interdisciplinary teams, services, and institutions to achieve
this value proposition. Business sectors involved in the deliv­
ery of healthcare include not only professionals such as
doctors, nurses, and administrators, but also hospitals, nursing
homes, and home healthcare groups; drug manufacturers and
developers; manufacturers of medical equipment and instru­
ments; diagnostic laboratories; biomedical researchers; and
biotechnological entrepreneurs.
Current estimates by the Office of Economic Cooperation
and Development place healthcare spending at 17.9% of the
United States’ gross domestic product, with that percentage
expected to increase to 19.5% by 2017.1 For every dollar spent
in the US on healthcare, 31% goes to hospital services, 21% to
physicians, 10% to pharmaceuticals, 6% to nursing homes,
4% to dental services, and 28% to other categories, such as
diagnostics laboratories, medical equipment, and medical
devices. Of note, 7% of total spending is assigned to admin­
istrative overhead costs.
If healthcare provided by physicians is not business, then
physicians are certainly surrounded by business; they
must navigate a complex environment that is full of para­
doxes, inefficiency, and bureaucracy. Unfortunately, physi­
cians receive no formal education in business but must learn
on the job, through mistakes and successes, often one patient
and one business problem at a time. Although many critics
argue that healthcare has been tainted by the intersection with
big business, which places the bottom line at the top and
undermines the physician–provider relationship, many other
thought leaders contend that healthcare needs business, to
help solve problems of inconsistent quality, rising costs,
limited access to care, and disparities in outcomes. Indeed,
business thinking and business processes are desperately
needed to transform our current system, so that healthcare
can be available to all people, at fair-market prices, to improve
the health of our community.
Why should plastic surgeons care about the business of
healthcare? From an individual perspective, every plastic
surgeon must either run a business or be part of a business,
if the surgeon’s practice is to thrive, grow, change, and con­
tinue to provide high-quality care. Whether one works for
oneself, for a hospital or health maintenance organization
(HMO), for an academic institution, for a non-profit or non-
governmental organization (NGO), for a free community
clinic, or for an overseas volunteer mission trip, plastic sur­
geons are involved with organizations that utilize business
principles and interface with business entities.
From a broader perspective, however, plastic surgeons are
uniquely situated to serve as leaders of healthcare systems
and healthcare businesses. Given our extensive training, our
collaboration with multiple specialties, our diverse portfolio
of services that we provide, our problem-solving skills, and
our entrepreneurial spirit, plastic surgeons have the leader­
ship skills, influence, and positioning within the healthcare
system to effect real change. Just as the Greek word plastikos,

43
Strategy
which means to shape or to mold, was chosen to describe
what we do as surgeons, this word could also impart upon us
the ability to shape or mold our systems of healthcare
delivery.
The knowledge and application of business principles is of
paramount importance if plastic surgeons are to become and
remain leaders in healthcare. The purpose of this chapter is to
provide a broad overview of the essential principles that
characterize what a business does and how a business does
its work. Each section offers a topical overview, and readers
are strongly encouraged to explore in more depth the follow­
ing components of this chapter:
1. Strategy
2. Accounting
3. Finance
4. Economics
5. Marketing
6. Operations
7. Innovation
8. Entrepreneurship
9. Sustainable enterprise
10. Human resource management
11. Legal and regulatory considerations
12. Negotiation
13. Ethics
14. Leadership
The end of each section will spotlight an “Idea Watch,” as a
forum to present novel, emerging, and occasionally contro­
versial topics related to business and healthcare. Featured
topics will be drawn from cutting-edge articles published in
the Harvard Business Review, with the goal of promoting
further reflection, analysis, and inquiry by the reader.
Plastic surgeons, at the very least, must learn the language
of business, to have meaningful interactions with hospital
administrators, insurance carriers, salespeople, and market­
ing firms. Hopefully, though, plastic surgeons can utilize the
principles of business to improve the care that we provide,
and in the end, to transform the industry in which we practice
our science, and our art.
Strategy
“Long-range planning does not deal with future decisions. It
deals with the future of present decisions… Significant
competitive advantage lies with those organizations and
individuals who anticipate well in turbulent times.”
Peter F. Drucker
Competitive advantage begins and ends with strategy (Box
5.1). Nearly all of the components of business are affected by
strategy, from finance to operations, from marketing to man­
aging human capital, and therefore a review of business
principles should commence with an understanding of how
strategy guides decision-making within an organization.
Strategy can be characterized as the art of inducing your
competitor to do something else, while you focus on doing
what you do well. In more academic terms, strategy is the
process of forming, implementing, and evaluating decisions
that enable an organization to achieve its long-term goals.
Fig. 5.1  Strategy: Porter’s 5-Forces model of competition. HMOs, health
maintenance organizations; PPOs, preferred provider organizations.
Threat of new entrants
Rivalry among
existing competitors
HMOs/PPOs, accountable care organizations,
out-of-state healthcare systems
Threat of substitute products or services
Alternative medicine, medical tourism
Insurers, state
Bargaining power
of suppliers
Supply chain
Patients
Bargaining power
of consumers
UNC/Rex, Duke,
Wake Med
Strategy is dictated by (and, in turn, can influence) the
organization’s mission, vision, and values, which serve as a
foundation to guide policy, projects, and programs. Further­
more, strategy is about competing on differentiation – creating
a value proposition – in which a firm provides the consumer
with a product or service of greater quality or at less cost than
its competitor, deliberately choosing a different set of activi­
ties to deliver a unique mix of outputs.
Before examining specific strategic principles, one should
become familiar with how the business environment affects
the flow of inputs to outputs, along the supply chain. Because
value is added at various points along this process, the entire
axis, from supplier to consumer, is called the value chain.
Primary activities of the company, which include inbound
logistics, operations, outbound logistics, marketing and sales,
and ultimately customer service, each create value that mani­
fests in the final product; these processes are guided by stra­
tegic priorities and are coordinated by support activities that
include technological development, human resource manage­
ment, and firm infrastructure.
The most established and respected model of the business
environment is Michael Porter’s 5-Forces model of competi­
tion (Fig. 5.1).2 Each industry contains: 1) previously estab­
lished competitors; 2) the potential for new entrants; 3) the
threat of substitute rivals, who often compete on price; 4)
suppliers, who can have significant bargaining power; and 5)
buyers, who create demand for the outputs. Understanding
the environment of a specific industry, such as healthcare, can
strengthen decision-making and help with strategic planning.
For example, how should an academic plastic surgery practice
respond to the influx of recently graduated residents into the
community? How should the solo private practitioner attract
new patients in a fixed market, when a group practice domi­
nates the landscape? How should surgeons challenge scope
of practice with non-surgeon physicians and non-physician
providers? What is the optimal portfolio of services, specifi­
cally the mix of reconstructive surgery, cosmetic procedures,
and skin care, to achieve the goals of the organization?
Once the dynamics and landscape of the business environ­
ment are defined, specific decisions can be made regarding
change in operations, marketing, investment in new assets,
alliances, or supply chain.3–5 Most mature industries, such as
the automotive industry or the personal computer industry,

44
CHAPTER 5 • Business principles for plastic surgeons
Accounting
“Nowadays, people know the price of everything and the value of
nothing.”
Oscar Wilde
Business management must be based upon a common
language that is used to objectively communicate information
related to the quantitative metrics of an organization. That
language is accounting (Box 5.2). This section will review the
tools that accountants use to assess the financial health of a
business: income statement, balance sheet, summary of cash
flows, and financial ratios.8–10 The nuances of accounting are
beyond the scope of this overview, but healthcare providers
must have a basic comprehension of these instruments and
how they represent the financial standing of their practice,
their hospital, and their healthcare system. Furthermore, these
instruments are used in budgeting to construct pro forma
predictions of future performance.
The field of accounting is governed by generally accepted
accounting principles, also known as GAAP, which are rules
used to prepare, present, and report financial statements for
various entities, such as non-profit organizations, publicly-
traded companies, and privately-held firms. Although the
government does not set these standards, the US Securities
and Exchange Commission does require that public firms
follow these rules. Managerial accounting, which is used to
allocate cost and assign overhead, does not follow GAAP and
is dependent upon institutional culture and practice.
Income statement
The income statement, also known as the profit/loss state­
ment, describes financial transactions within a defined period
of time, which may be quarterly or annually. Revenue refers
to the gross income that a company receives from normal
settle into a competitive scenario in which one firm dominates
with 60% market share, while a second firm contains 30% of
the market share, and the remaining competitors occupy 10%.
Because of barriers to entry, new entrants may not be able to
successfully compete, unless disruptive technology lowers
production costs or the market shifts, due to cultural, social,
economic, or political forces. In fact, significant competitive
advantage is conferred to small, nimble firms that focus their
product line or services and offer a unique selling proposition,
to a targeted segment of the market. When executed correctly,
this activity, termed “judo strategy,” has the power to
undermine dominant businesses and increase market share
substantially.
A major limitation of competitive strategy is that most
efforts deal with gaining a larger portion of a fixed market or
attracting new customers via the “rising tide” of a slowly
growing market. If companies in search of sustained, profit­
able growth compete with multiple rivals, then differentiation
becomes difficult, price wars may ensue, and the total profit
pool shrinks. Instead, companies may pursue a “blue ocean
strategy,” in which uncontested but related market space is
discovered, rendering rivals obsolete and generating new
demand. Previous “settlers” will “migrate” to this new market
space and become “pioneers.” Apple has done this over and
over with the personal computer market, introducing new
devices that expand the functionality of their operating system
and hardware, evidenced by the transition from desktop to
laptop to iPhone to iPad.
True value innovation comes when a company jumps out
of their industry and creates an entirely new market, often in
a different industry.6,7 This foray into uncharted territory,
which is referred to as “white space,” typically occurs when
a company develops a disruptive technology that permits the
use of core competencies to produce a radically different
product or service. Apple was successful in capturing the
dominant position in the digital music market by designing
and offering iTunes, despite being a computer company.
Inherent to this success was the fact that Apple also changed
the business model for purchasing music; consumers could
buy singles or albums, listen to samples, and of course, use
the website for free. As the music industry shifts again, from
purchasing content to subscription services as a major revenue
model, Apple is determined to remain the dominant player.
The acquisition of the Beats music platform will allow Apple
to compete with Pandora and Spotify, but also serve to stream
video content for gaming and on-demand viewing of televi­
sion and film.
In summary, strategy involves the following steps:
1. Industry analysis – assess industry profitability today
and tomorrow
2. Positioning – identify sources of competitive advantage
3. Competitor analysis – study current competitors, future
entrants, and substitutes
4. Assessment of current strategy – predict effectiveness
and sustainability
5. Option generation – search for new customers, new
segments, new markets
6. Development of capabilities – planning now for future
opportunities
7. Refining strategy – assess uniqueness, trade-offs,
compatibility with vision and values
BOX 5.1  Idea watch: strategy
Reference: Raynor ME, Ahmed M. Three rules for making a
company truly great. Harvard Business Review. 2013;91:108–117.65
How do great companies make great strategic choices? The
authors studied 25 453 businesses, operating over a 44-year period,
and identified several hundred that had exceptional, sustained
performance. The decisions that allowed certain companies, like
IBM, 3M, Merck, and Medtronic, to outperform their peers, followed
three simple rules:
• Better before cheaper (compete on differentiators other than
price)
• Revenue before cost (prioritize increasing revenue over reducing
costs)
• There are no other rules (to change anything you must follow
the first two rules)
These rules did not dictate specific behavior, or even general
strategies, but instead served as foundational concepts, or guides,
when making strategic decisions about acquisitions, diversification,
resource allocation, and pricing. Competitive positions built on
greater differentiation through brand, style, or reliability were more
likely to drive exceptional performance than positions built on lower
prices.

45
Accounting
include short-term loans (credit lines) current portion of long-
term debt, accounts payable (the money a company owes its
vendors), and long-term debt.
Owners’ equity – the difference between assets and
liabilities – can be allocated into several categories: preferred
shares (which usually receive periodic dividends), common
stock, and retained earnings (accumulated earnings that have
been reinvested into the business, instead of being distributed
as dividends).
Summary of cash flows
An assessment of a company’s cash flows is critical in deter­
mining the financial viability of the firm, because profit is
NOT the same as cash. This disconnect is due to multiple
reasons: 1) cash may be coming in from investors or loans; 2)
revenue is booked at time of sale, not collection; 3) expenses
are matched to revenue, not when they are actually paid; and
4) capital expenditures do not count against profit (because
only the depreciation is charged against revenue) but require
cash or debt to pay for the assets. As a result of this discrep­
ancy between when a good or service is provided and when
cash is exchanged, following the flow of cash can be very
complicated. Fortunately, we have accountants. For mature,
stable, and well-managed companies, cash flow does approxi­
mate net profit. But for younger, growing, and poorly-managed
companies, profit can occur without gaining cash (resulting
in bankruptcy, because bills cannot be paid) or cash can accrue
without being profitable (which bodes poorly for long-term
success, if expenses cannot be controlled).
Overall cash flows are further subdivided into three catego­
ries – operations, investing, and financing – based upon the
conduit for the flow. Cash flows from operating activities
(CFO) indicate how much cash was generated from opera­
tions: selling goods and services. Cash flows from investing
activities (CFI) indicate how much cash the company spent
(or received) from buying and selling businesses, property,
plant, and equipment. Finally, cash flows from financing
activities (CFF) indicate how much cash the firm borrowed,
received from selling stock, or used to pay down debt or
repurchase stock.
Total cash flow represents the true flow of money through
a firm and is a composite of the operations, investing, and
financing, represented by the following equation:
Total cash flow
CFO
CFI
CFF
=
+
+
Many financial analysts believe that total cash flow myopi­
cally focuses on earnings while ignoring “real” cash that a
firm generates and retains for future investments. Therefore,
another measure of the ability of a firm to create value is free
cash flow (FCF), which is defined numerically as:
Free cash flow
CFO
capital expenditures
or alternatively
Fr
=
−
:
ee cash flow
net income
amortization
depreciation
change
=
+
+
−
in working capital
capital expenditures
−
In other words, free cash flow represents the total cash that a
company is able to generate after laying out the funds required
business activities, typically the sales of goods or services, but
may also include rent, dividends, or royalties. In accrual
accounting, revenue occurs at the time of the transaction, not
when receipts are collected. Net income is expressed as a
profit or loss, after deducting expenses, which usually include
operating expenses (cost of goods sold, variable overhead
expenses), depreciation of assets and amortization of leases,
fixed overhead (selling and administrative expenses, research
and development), interest expenses, and taxes.
Revenue
Gross profit
less
Operating costs
less
Fixed overhead
le
=
ss
Depreciation assets and amortization leases
(
)
(
)
= Operating income EBIT
Pre-tax income
(
)
less
Interest expenses
less
Income
=
taxes
= Net income
Balance sheet
The balance sheet is a snapshot of what the company owns
and owes, at a single point in time. On one hand, the balance
sheet summarizes the cumulative impact of all transactions,
but the balance sheet does not provide much useful informa­
tion on the operational performance of the firm. The net worth
of the company, referred to as owner’s equity, is defined as
the difference between the assets and the liabilities.
Equity
Assets
Liabilities
=
-
However, balance sheets usually frame this relationship
slightly differently, but again, the following equation must
always balance:
Assets
Liabilities
Equity
or
Assets
Debt
Equity
=
+
=
+
The actual worth of a company, the equity, is difficult to
ascertain, but one method to calculate value is market capi­
talization, which is (share price) × (shares outstanding); this
represents the public consensus of the value of the firm’s
equity.
Assets are defined as resources with probable future
economic benefit, obtained or controlled by the entity, as a
result of past transactions, that are expected to contribute to
positive net cash flows. Examples of assets include cash and
cash equivalents (pre-paid expenses, bonds, stock), accounts
receivable (the money that is owed but has not been collected),
inventory (raw materials, work-in-process, and finished
goods), property/plant/equipment (purchase price less
depreciation), goodwill (intangible value of brand), and intel­
lectual property.
Liabilities refer to what a company owes, or from a differ­
ent perspective, how the assets were obtained. Liabilities

46
CHAPTER 5 • Business principles for plastic surgeons
to maintain or grow its asset base. FCF is very important to
investors because this allows a firm to pursue opportunities
that increase shareholder value. This is the best source of
capital for development of new products and services, acquir­
ing new companies, paying stock dividends, and reducing
debt. Cash really is king, and this is why.
Financial ratios
Because companies even within a single industry can vary in
size and maturity, such instruments as the income statement,
balance sheet, and summary of cash flows may not permit a
valid comparison of those companies. Instead, financial ratios
– the numerical relationship between two categories – can
provide powerful insight into the financial health of a
company. Jonathan Swift observed that “vision is the art of
seeing what is invisible to others,” and financial ratios provide
that vision.
Four types of ratios help managers and stakeholders
analyze a company’s performance: profitability, leverage,
liquidity, and efficiency. These ratios can be used to follow the
performance of a firm over time or to compare several firms
across related industries.
Profitability ratios
Gross margin
gross profit revenue
Operating margin
operating
=
=
profit revenue
Net margin
net profit revenue
=
Return on assets
net profit total assets
net income revenue
=
= (
)
(
)
× revenue assets
Return on equity
net profit shareholders’equity
=
Contribution margin
revenue
variable direct costs
technica
=
−
(
lly not a ratio but
loved by CFOs everywhere
,
)
Leverage ratios
Debt-to-equity ratio
total liabilities shareholders’equity
I
=
nterest coverage
operating profit annual interest charges
=
Liquidity ratios
Current ratio
current assets current liabilities
Quick ratio
=
=
−
(
)
current assets
inventory
current liabilities
Efficiency ratios
Days in inventory
average inventory
CO
cost of goods sold [
=
(
GS /day
Inventory turns
days in inventory
Days sales ou
]
)
= 360
tstanding
accounts receivable revenue/day
Days payable ou
=
(
)
tstanding
accounts payable COGS/day
property, plant, equi
=
(
)
pment (
)
PPE turnover
revenue PPE
Total asset turnover
reven
=
=
ue total assets
BOX 5.2  Idea watch: accounting
Reference: Kaplan RS, Porter ME. How to solve the cost crisis in
health care. Harvard Business Review. 2011;89:46–64.66
Stephen Kaplan, who engineered the concept of time-driven,
activity-based costing, collaborated with Michael Porter, who
introduced the idea of the value creation to supply chain theory, to
develop a new model for determining the true cost of providing
healthcare.
In the process, they identified 3 myths that needed to be
challenged: 1) charges are a good surrogate for provider costs;
2) hospital overhead costs are too complex to allocate accurately;
and 3) most healthcare costs are fixed. Kaplan and Porter proposed
methodology to calculate the total cost of patient care, based on
blending the cost of resources needed to provide care, the time
needed to provide that care, and the utilization and capacity of that
resource. By using sophisticated managerial accounting, they
discovered several opportunities to improve value:
• Eliminate unnecessary process variations and processes that
don’t add value
• Improve resource capacity utilization
• Deliver the right processes at the right location
• Match clinical skills to the process
• Speed up cycle time
• Optimize over the full cycle of care
The remedy to the cost crisis does not require breakthroughs in
medical science or new governmental regulation, but rather
improved ways to accurately measure costs and compare them with
outcomes. Educating and engaging all members of the healthcare
team, through process mapping of patient care delivery, has the
potential to reduce costs while improving outcomes.
Finance
“Markets are constantly in a state of uncertainty and flux and
money is made by discounting the obvious and betting on the
unexpected.”
George Soros
The goal of finance (Box 5.3) is to maximize corporate value
while minimizing the firm’s financial risks.11 If accounting is
the language and grammar of business, then finance is a
combination of poetry and theoretical physics, with some rock
‘n’ roll added to keep the mix interesting. The central thesis
of finance is that risk can be managed successfully, in such a
way that wealth is created, by combining the variables of cash,
assets, supply chain, and human capital, to produce a good
or service that is more valuable than the cost of production.
The consumer, however, is the final arbiter who decides if the
good or service is more valuable than the cost of the inputs,
and if the output is more valuable than the price the consumer
is willing to pay. If so, the consumer exchanges money for the
good or service.
Risk can be measured statistically and therefore, given
assumptions that are known with certainty, the outcome of
decision-making can be predicted with specific probability.
Thus, the decision to make an investment in a new piece
of equipment, a new employee, a new product line, or to
purchase another company, can be made with a certain
level of confidence. However, when some variables are

47
Finance
money, and energy in that project or asset, when those
resources could be invested elsewhere. The definition of
opportunity cost is the potential benefit forgone from not
following the financially optimal course of action. Rather than
thinking in yes/no parameters, the investor should make
either/or decisions, searching for other opportunities, until he
or she can compare the proposed course of action with the
next best alternative. In the world of surgery, where most of
physician revenue is generated from procedures, any activity
that takes the surgeon out of the operating room should be
carefully compared to what the surgeon could accomplish by
staying in the OR.
Net present value (NPV) and discounted cash
flows (DCF)
The decision to pursue a project, when economic consider­
ations are important, involves determining the net present
value of that opportunity. NPV is calculated by adding a
time-series of cash flows, both incoming and outgoing, that
the project is expected to produce, over a series of future
periods. This calculation would include the initial cost of
purchasing the asset, at DCF0, plus the anticipated revenue
that the asset would generate, from DCF1 to DCFn. Each future
cash flow must be discounted back to its present value.
NPV
DCF
DCF
DCF
DCF
where n
number of periods
n
n
0
0
1
2
−=
+
+
+
+
=
…
If the NPV is >0, then the investment would add value to the
firm, and the project may be accepted. If the NPV is <0, then
the investment would subtract value from the firm, and the
project should be rejected. The discount rate selected is often
the firm’s weighted average cost of capital (WACC), which
blends the cost of debt (borrowing money) with the cost of
equity (shareholders’ expected returns on their stock). Another
approach in selecting the appropriate discount rate is to
determine the rate that another investment would yield, if this
capital were used in a different project. This required rate of
return is often referred to as the hurdle rate, which is higher
for riskier projects and lower for safer ones. The hurdle rate
represents the expected rate of return for risk-free projects
(tied to the US Treasury bill) plus the potential rate of return
for risky projects.
Return on investment (ROI)
After one has projected future cash flows for an investment,
how can one evaluate these future cash flows, in terms of the
value of this investment? Several approaches are helpful in
deciding the potential value of future ventures and in retro­
spectively examining the actual value of past ventures. These
methodologies include: formal ROI or yield, the payback
method, the internal rate of return (IRR), and the NPV/DCF
model. The most rigorous and powerful technique is NPV/
DCF analysis, but limitations include multiple assumptions
regarding future cash flows, selecting the appropriate dis­
count rate, and complexity of the calculation. As a result,
predictions using NPV tend to be conservative, but at least
they incorporate the time value of money, so that the investor
can make decisions based on the value of today’s dollars.
unknown (ambiguity) or when no variables are known (true
uncertainty), sound financial management may not be possi­
ble, to the point that flipping a coin may provide more insight
regarding outcomes.
This section will introduce common tools used by financial
managers when analyzing a financial scenario, to determine
go/no-go decisions about acquiring and allocating assets.
While understanding the mechanics of such calculations is not
essential, understanding the logic behind the decision-making
is critical, as well as understanding the significance of the
results. We will review the following concepts: Time value of
money, opportunity cost, net present value (NPV), discounted
cash flows (DCF), weighted average cost of capital (WACC)
and the hurdle rate, return on investment (ROI), and internal
rate of return (IRR).
Time value of money
Money increases in value over time, and such appreciation is
actually logarithmic (although it takes a while to get going!).
Even Einstein conceded, “The most powerful force in the
universe is compound interest.” Essentially, a dollar today is
worth a slightly more tomorrow and a lot more in ten years.
A dollar invested in a money market account with an annual
return of 2% will yield 2 pennies next year, increasing the
value of this investment to $1.02, which is future value of
today’s dollar. The formula for the time value of money is:
Present value PV
future value
interest rate
of periods
(
)
(
)#
=
+
1
Why does money have a time value? Economists attribute this
to two factors: postponement of consumption and expecta­
tions of inflation. Interest rates are a hedge against this type
of depreciation. As risk of an investment increases, then the
reward to the investor needs to increase, to convince the
investor to part with one dollar today, in hopes of having
possibly $1.20 next year (which would be a 20% return). The
actual rate that money can appreciate is determined by mul­
tiple factors, such as the risk of the specific investment, the
performance of the stock market, the return on US Treasury
bonds, and the monetary policy established by the Federal
Reserve, which sets the overnight lending rates to commercial
markets.
Consequently, obtaining capital costs money. If one borrows
money from the bank, this loan creates risk for that institution,
so the bank will need to collect more money from the bor­
rower, when the debt is repaid, at some point in the future.
But here is the catch: banks need to charge not only for the
time value of money, which is their expected rate of return
(also called the discount rate), but the bank must also hedge
against your riskiness as a borrower, driving up the cost of
capital and increasing the interest rate that you must pay. In
fact, if the bank can make a safer investment, with a possibly
higher rate of return, then the bank should not pursue the
loan.
Opportunity cost
When considering a new project or purchasing a piece of
equipment, one should proceed if the intrinsic value of the
asset equals or exceeds its cost. What one must also consider,
though, is the opportunity cost of tying up precious time,

48
CHAPTER 5 • Business principles for plastic surgeons
which may vary for different projects, depending upon the
risk, the time horizon for the returns, and the cost of capital
for the firm or WACC. Another way of understanding this
method is that IRR represents the hurdle rate necessary to
make NPV = 0. Problems with using IRR include not quantify­
ing the overall value of the project, as well as how long the
company can anticipate the length of the return. Nevertheless,
IRR, payback method, and yield are helpful when communi­
cating potential ROI to stakeholders, because of their simplic­
ity and ease of understanding.
Economics
“Economists are about as useful as astrologers in predicting the
future (and, like astrologers, they never let failure on one
occasion diminish certitude on the next).”
Arthur Schlesinger, Jr.
The sheer enormity of the field of economics prohibits a
detailed review in this setting, but nevertheless, key concepts
can be outlined. The entire discipline ranges from macroeco­
nomics to microeconomics, from normative economics to
behavioral economics, from heterodox economics to game
theory (Box 5.4).
Like other branches of economics, healthcare economics
deals with decision-making in the setting of uncertainty,
limited resources, and variable demand.12–15 However, health­
care economics is distinctly different from other branches of
economics, because healthcare is an industry that includes
extensive government intervention and regulation; asymme­
try of information between provider, patient, and payer; lack
of precise metrics, with regard to patient outcomes; and
considerable externalities, which are the downstream effects
on other entities, outside of the healthcare system.
Demand for a good or service is based upon a buyer’s
willingness to pay, which in turn is influenced by the buyer’s
tastes or needs, the consumer’s income or wealth, and the
availability of substitute and complementary goods. Demand
curves can then be constructed to describe an individual’s or
a population’s willingness to purchase: as price increases,
demand decreases. Price elasticity represents the change in
quantity demanded as a function in change of price and is
crucial to the way that markets adjust. Mathematically, this
relationship can be expressed as:
E
delta Q delta P
where E is the coefficient for the price
d
d
=
elasticity of demand
(Although Ed is almost always negative, economists typically
use the absolute value of Ed, making this a positive number)
Q
quantity of good or service
P
price of good or service
=
=
Elasticity coefficients can be interpreted as follows:
E
perfectly inelastic demand
E
relatively inelastic
d
d
=
−<
<
0
1
0
demand
E
unitary elasticity
E
elastic demand
E
per
d
d
d
= −
< −
= −
1
1
1 0
fectly elastic demand
A much simpler approach to calculating ROI is yield, which
is represented by the following formula:
Yield
gain from investment
cost of investment
cost of inv
=
−
(
)
estment
Yield, however, is expressed as a percentage, and therefore
gives little information about the magnitude of the value of
the investment. Furthermore, yield can be easily manipulated
by using varied metrics to define “gain” and “cost.” Yield is
helpful when comparing similar products or services, within
a market or industry.
The payback method, which measures the time required
for the cash flow from the project to pay for the original
investment, is also quite popular with mid-level managers,
who need to justify the purchase of capital equipment and
predict time to break-even.
Payback time
cost of investment annual cash flow
=
What payback period does not take into account is deprecia­
tion of the equipment, useful lifespan of the asset, and residual
value of the asset at the end of the period. Furthermore, cash
flows for a project or asset usually change from year to year,
and therefore the payback period only estimates when the
project or asset reaches break-even. If the useful life of the
investment is greater than the payback time, then the invest­
ment should be pursued, at least for financial reasons.
Another technique used to assess ROI is the internal rate
of return, or IRR. Instead of assuming a particular discount
rate for an investment and calculating the NPV, the IRR
method determines the actual return projected by the cash
flows. The IRR is then compared with the firm’s hurdle rate,
BOX 5.3  Idea watch: finance
Reference: McGrath RG. Transient advantage: strategy for turbulent
times. Harvard Business Review. 2013;91:62–70.67
Given the volatility of the economic markets over most of the
21st century, the previous dogma that strategy consists of
establishing a unique competitive position, sustained for long
periods of time, may no longer be relevant for many businesses. In
the age of information, transient advantage may be the new
normal. Businesses must learn to launch new strategic initiatives,
again and again, based on a new set of operational capabilities.
Just like a diversified portfolio of assets may hedge against risk, a
portfolio of advantages that can be quickly built, and quickly
abandoned, may improve the financial position of the company, by
maintaining multiple revenue streams that result in combined net
positive cash flows.
McGrath warns that businesses operating in a high-velocity
setting will need to avoid traps previously viewed as advantages:
first-mover, total quality management, white space positioning, and
incremental innovation. Instead, companies should consider the
following shifts:
• Think about arenas, not industries
• Set broad themes, and then let people experiment
• Adopt metrics that support entrepreneurial growth
• Focus on experiences and solutions to problems
• Build strong relationships and networks
• Avoid brutal restructuring; learn healthy disengagement
• Get systematic about early stage innovation
• Experiment, iterate, learn.

49
Marketing
distribution of wealth in society. A final quandary to ponder:
not all of the costs and benefits of a transaction accrue to the
buyer and the seller. These externalities – downstream effects
on society – may be beneficial (new technology that extends
life), but are too often detrimental (production of medical
waste products). How can we incorporate these externalities
into our decision-making, so that we increase the total social
value of our actions?
Marketing
“Good companies will meet needs; great companies will create
markets.”
Philip Kotler
Business could not exist without the customer, and marketing
is the process that enables business to connect with the
customer (Box 5.5).16,17 Marketing strategy identifies, attracts,
satisfies, and retains customers. Seeking to build more than a
single exchange between the producer and the consumer (or
in healthcare, the provider and the patient), marketing is first
and foremost driven by customer needs and desires. The ideal
approach in marketing is initially to understand the custom­
ers in the context of their environment, which includes not
only assessment of market size but also competitive forces,
barriers to entry, and market structure. Next, marketing seeks
to develop a specific product or service offering, based upon
Goods or services with close substitutes, such as Botox® and
Dysport®, have a flat, elastic curve, in which small changes in
price produce large changes in demand. Other goods and
services may have steep, inelastic demand curves, in which
large changes in price may have minimal effects on demand;
this is the case for necessities with few substitutes, some
luxury items, and products with intense brand loyalty. Price
elasticity for a given good or service may also vary, based
upon the specific segment of the market targeted, and may be
influenced by macroeconomic forces. When the purchaser
does not directly pay for the good consumed or the service
provided, such as a patient whose surgery is paid for by
third-party insurance, price elasticity is likely to be relatively
inelastic. Adding a copay or deductible transfers some of the
cost to the consumer and increases the elasticity of demand
for healthcare.
Supply of a good or service depends on a firm’s short-term
and long-run strategic goals. Decisions about supply are
based initially on marginal costs, which vary with level of
production. As production increases, so do marginal costs.
However, average fixed costs decrease with increasing
volume. These curves are combined to produce a U-shaped
curve of average total cost, the nadir of which is the lowest
price that the firm can charge and break even. A company can
offer a good or service, as long as the market price remains
above the average total costs. An aggregate market supply
curve demonstrates that as price increases, more firms are
willing and able to produce outputs.
Market equilibrium occurs when the supply and demand
forces adjust to a price and quantity that satisfy both produc­
ers and consumers. Markets will move in predictable ways,
based upon changes in supply and demand. Increased supply
causes the equilibrium price to fall and the equilibrium quan­
tity to increase. Conversely, new demand for a product or
service will cause the equilibrium price to rise, with a subse­
quent increase in the equilibrium quantity.
Real markets, however, are messy and may behave in ways
that only approach these rules. For these economic models
to work, markets must have perfect competition, in which
products are identical, sellers and buyers do not engage in
strategic manipulation of supply and demand, players make
rational choices, entry and exit barriers are non-existent, and
participants are fully informed. Such a market does not exist.
Predicting how economic forces shape the healthcare market
is a considerable challenge, given that such competition is far
from perfect.
Firms can gain strategic advantage, then, by exploiting
the inefficiencies of the market. Ethical approaches include
product differentiation, segmentation of the market, respond­
ing to new cultural, social, and political shifts, and using
technology and innovation to create new value propositions.
Unethical tactics would involve maintaining an asymmetry of
information between consumer and producer, taking advan­
tage of irrational decision-making, artificially creating demand
or limiting supply, collusion with other players, and creating
impassable barriers of entry for new participants. In the
healthcare industry, providers must remain cognizant of these
opportunities – both ethical and unethical – and maintain a
level of responsibility that ensures professionalism at all times.
In summary, markets strive for equilibrium, but adjust­
ments in supply and demand may not lead to productive
efficiency, which by itself is not a guarantee of the fair
BOX 5.4  Idea watch: economics
Reference: Kaplan RS, Porter ME. Motivating salespeople: what
really works. Harvard Business Review. 2011;90:71–75.68
How do we improve the productivity of our employees? In
healthcare, providers are expected to see more patients, improve
quality of care, and optimize patient satisfaction, often with reduced
resources. Fundamentally, incentivizing physicians, nurses, and
therapists is a microeconomic problem, in which incentives should
be aligned with performance to influence behavior. Laggards, Core
Performers, and Stars each respond to different rewards, and
therefore compensation plans should be structured differently to
induce a higher level of productivity. Companies that structure their
incentive plans based on these differences will realize better results
across the performance curve:
Motivating Laggards
• Recognize, first, that this group is heterogeneous and can
include new hires, complacent senior providers, and people
who are just less talented than their colleagues; one size does
not fit all
• Introduce more frequent, pace-setting bonuses
• Create natural, cultural, and program-specific social pressures
Motivating Core Performers
• Establish multi-tier targets for productivity
• Have sales or performance contests with awards that vary in
nature and value
Motivating Stars
• Avoid ceilings on pay; controlling costs also encourages the
stars to quit working
• Develop super-achievement commission rates.

50
CHAPTER 5 • Business principles for plastic surgeons
anticipated customer needs that may or may not be adequately
met, or may not even be appreciated. Finally, marketing
strives to deliver customer value, in the form of price point,
quality, and distribution.
Although marketing strategy has been often oversimplified
by focusing on the “4Ps” – product, price, promotion, place­
ment – this is a good starting point for our review. Product
refers to the characteristics and defining features of a good or
service. Price is determined by factoring in cost of production
with what additional value can be extracted by the producer,
based upon value-added features and the demand for the
good or service. Calculating break-even volume is important
to determine if a pricing strategy is reasonable. The formula
for finding out how many units a company must sell, so that
its costs are covered, is represented as follows:
Break-even unit volume
fixed costs
sales price
variable co
=
−
(
sts)
To achieve a specific profit target, the formula can be modified
as follows:
Volume
fixed costs
total profit
sales price
variable cos
=
+
−
(
)
(
ts)
Promotion involves the channels that will be necessary
through which the company can communicate its message
and may involve advertising, use of a sales force, or incentives
(bundled pricing, discounts, rewards, and frequent buyer
benefits, for example). Placement is arguably the most impor­
tant of these variables; marketing experts segment a general
market to determine what types of people (young vs old, male
vs female, high income vs low income) desire what types of
products. Segmentation allows for better allocation of a com­
pany’s finite resources, enables the firm to target specific
high-yield groups, and improves positioning of the product
for higher market penetration. In fact, a company can offer
related but slightly different products if marketing research
demonstrates that multiple segments have slightly different
needs. Instead of pursuing a one-size-fits-all philosophy and
missing segments of the market, a firm can employ marketing
analysis to justify, with confidence, multiple offerings of
related products.
Over the past two decades, in which consumers have been
empowered by the internet (online auctions, availability of
product reviews, and easy comparison of prices), marketing
has shifted from a supply-side model to a demand-based one,
in which customers’ perspectives are factored into the
supplier-centric approach of the 4Ps. Products are now viewed
as solutions for the customer, promotion now includes trans­
fer of information, price has been replaced by consumer value,
and placement is viewed as access.
To identify market segments that might purchase a product
or service, and to determine what qualities that segment
would find most valuable, marketing research utilizes complex
analytical tools such as regression analysis, conjoint analysis,
perceptual maps, and scenario planning to make decisions.
Fig. 5.2 demonstrates the crowded landscape of facial rejuve­
nation, in which patients may choose from a number of
interventions, based upon such parameters as price, durabil­
ity, invasiveness, and time to recovery. Marketing seeks to
identify which customers want what procedures and to target
that group specifically. Occasionally, uncontested market
Fig. 5.2  Marketing: perceptual map of facial rejuvenation.
Cost of procedure
Durability of procedure
Facelift
Neurotoxin
Short-term filler
Volumetric filler
Dermabrasion
Chemical peel
Fractional laser
Ablative laser
Threadlift
Open market space
space is discovered, based upon changing customer prefer­
ences, or opens up, due to advances in technology.
The act of connecting customer to product or service is
central to the charge of marketing and can reap tremendous
returns, in terms of revenue, branding, and goodwill. As such,
marketing is viewed as an investment by the company, similar
to research and development, in which return on investment
is predicted and carefully studied, along with other metrics
such as market share, customer attrition, customer satisfac­
tion, exchanges and returns, and size of accounts receivable.
Other research tools include customer focus groups, demo­
graphic data, and customer questionnaires.
In addition to using such strategies as segmentation, target­
ing, and positioning, marketing also can utilize branding as a
powerful tool to communicate the qualities of a new offering.
In many ways, a strong brand serves, albeit not legally, as a
promise that the new product or service will be similar to
previous offerings. Branding can include a logo, phrase,
image, or feeling that serves as a placeholder for the company
and its reputation.
One strategy that is not particularly effective but must be
mentioned, to warn against, is that of perceptual shifting. This
occurs when: 1) promotion attempts to shift the needs and
desires of a targeted group, so that they believe that they need
or desire the product or service; or when 2) promotion shifts
the perceived qualities of the offering, so that these features
more closely correspond with the needs and desires of the
targeted group. Such a strategy will produce a very short-
term effect, which may temporarily improve sales, but will
have disastrous long-term effects on the relationship with the
customer. This strategy is employed when firms do not desire
repeat transactions with their customer or when a product is
reaching obsolescence and the entire industry is shrinking.
With the recent decline in print media and other traditional
communication outlets such as radio and network TV, mar­
keting has turned to the internet to promote goods and ser­
vices, provide information to the consumer, and match the
appropriate offering with the correct group. Many economists
arguably contend that in our new digital age, the cost of
storing information is approaching zero and the value of

51
Operations
information may creep toward infinity.63 Despite whether or
not this can be proven, it is clear that digital information has
completely changed the rules of marketing. Companies can
gather specific information about consumers, based upon
their shopping habits at Amazon, their friends on Facebook,
what they write on blogs in the Huffington post, and what
articles they read at CNN.com. For a fraction of the cost of
traditional media, firms can reach out to their customers
through direct email or via search engines. Marketing depart­
ments now focus on search engine optimization and search
engine marketing. As some companies experiment with new
revenue streams, both online and offline, some products may
be offered for free, while related services may cost a premium.
Operations
“Any customer can have a car painted any color that he wants,
so long as it is black.”
Henry Ford
Operations can be defined as matching supply with demand
(Box 5.6).18,19 Although economists can describe how prices
change with alterations in supply and demand, managers
responsible for production of inventory or for coordination of
services have an entirely different perspective: excess demand
is lost revenue, and excess supply is wasted resources. How the
manager balances supply and demand determines not only
potential revenue from goods and services but also operating
costs, which together yield operating income for the firm.
Operational effectiveness is critical to the firm’s success; in
fact, this can be a source of competitive advantage. Companies
that get more from their inputs, or use fewer inputs, to produce
higher quality outputs will be able to offer goods or services
at lower costs than their competitors or extract more financial
value from these goods and services. This flow of inputs to
outputs is also called the supply chain, and when managed
well, adds value to the final product, before this is passed on
to the consumer.
To optimize the flow of this value chain, the field of opera­
tions utilizes elements of queueing theory to predict and
control demand, as well as the theory of constraints, to predict
and control supply. Perhaps the greatest challenge in deter­
mining demand for a good or service is variability. In medicine,
for example, long clinic waits to see a physician are often due
to variability in patient arrival times, which is compounded
by a variability in service times by the provider. This is why
patients of a certain type are often scheduled in batches, to
minimize the variability on both sides of the equation. In the
service industry, key metrics that should be tracked, in an
effort to improve operational effectiveness, include:
Capacity
Capacity util
= maximum supply a process can generate
ization
Throughput time
=
=
+
arrival rate service rate
wait time
service time
service rate
capacity utilizati
Flow time =
−
(
) (
1
1
on)
Inventory =
×
average flow rate
average flow time Little’s Law
(
)
Inventory turns =
=
1 flow time
COGS inventory
Bottlenecks in the production process (for goods) or delivery
process (for services) occur when the demand at a specific
station in the flow process is greater than the outputs pro­
duced at that station. At any given point, a process has
technically only one bottleneck, which is defined as the
resource with the lowest capacity. Flow through a station can
be measured to identify the bottleneck, but this point of
constraint is often evident by high utilization, no slack or
buffer, piled-up inventory, and complaints from workers and
consumers.
Principles used to match supply with demand include:
1. Since the limiting resource defines capacity, focus on
improving output at the bottleneck (this, of course,
creates a new bottleneck somewhere else in the
system).
2. Maintain enough inventory and work-in-process to keep
the pipeline flowing, to prevent stock-out, and to
anticipate variability in demand, but not too much that
capital is over-invested on unfinished goods or unused
services.
3. Systems or stations operating at close to 100% capacity
are not sustainable; 80% utilization is considered to be a
reasonable target.
4. Plan carefully, as variability and uncertainty can
propagate along the supply chain, creating a bull-whip
effect of increasing impact that yields far too much or
far too little output.
5. Prevention costs less than inspection and correction;
never add value to a part that is defective.
6. Never allow the cause of the problem to persist by
working around it.
7. High quality is not free, but it can be a great
investment.
BOX 5.5  Idea watch: marketing
Reference: Avery J, Fournier S, Wittenbraker J. Unlock the mysteries
of your customer relationships. Harvard Business Review.
2014;92:72–81.69
Many consumer companies, including service industries like
healthcare, lack relational intelligence and do not appreciate the
different kinds of relationships that their customers have with their
brand, their product, and their service. Each type of customer
relationship is based on that customer’s experience, expectations,
and future desires.
Customers can now be described as strangers, flings,
acquaintances, buddies, teammates, best friends, and even
enemies. As such, marketing divisions must crunch big data to
determine the signal within the noise, in terms of providing the right
customer with the right product or service within the context of the
right experience. Meeting or exceeding consumers’ needs must still
occur, but marketing experts must consider the new rules, which
include:
• Bolster desired relationships
• Renegotiate existing relationships
• Reorganize marketing strategy around relationships
• Create new roles for employees to develop relationships
• Expand the marketing umbrella within the organization create a
culture of relationship-driven strategy

52
CHAPTER 5 • Business principles for plastic surgeons
terrorists should not be pursued and hostages should be let
go. In healthcare, patients who are not completely satisfied or
mostly satisfied will find other providers.
Innovation
“Companies that enjoy enduring success have core values and a
core purpose that remain fixed, while their business strategies
and practices endlessly adapt to a changing world.”
James Collins and Jerry Porras
Whereas the field of operations provides value through incre­
mental improvement, innovation (Box 5.7) produces radical
or revolutionary changes in thinking, design, products, pro­
cesses, and even organizations.22–25 Operations serve to exploit
existing inefficiencies, with the goal of lower costs, faster
production, and higher quality, via such interventions as
tighter supply chain coordination, lean manufacturing tech­
niques, and zero-defect policies. Innovation, on the other
hand, disrupts the current paradigm and not only expands
the existing market but may create entirely new markets.
Thomas Krummel, a pediatric surgeon who directs the Stan­
ford Biodesign Program, describes a sequence of discovery,
invention, innovation, and entrepreneurship that is the blue­
print for translational medicine.24 More importantly, he asks,
“why should innovation be left to chance?” and provides a
cogent argument for studying, understanding, and teaching
innovation. Medical knowledge can be utilized directly in
patient care, but training other physicians, developing new
solutions, and applying new technologies can increase the
impact of surgeons exponentially.
A reasonable question, which has a surprising answer, is
“why do we need to innovate?” Peter Drucker, in fact, wrote
that the two essential functions of a company are innovation
8. Forecasts are always wrong, sometimes more so than
others.
9. Service industries face unique challenges that involve
customization of the output and high degree of labor
interaction.
In an effort to improve operational efficiency, a number of
methods have been developed to reduce defects, increase
throughput, and improve quality. Lean manufacturing is a
production process in which any expenditure or resource that
does not add value to the customer is a target for elimination.
Originally developed by Toyota, lean manufacturing attempts
to “work smarter, not harder” by reducing or eliminating
seven sources of waste: overproduction, unnecessary trans­
portation, inventory, motion, defects, over-processing, and
waiting. Although this approach yields only incremental
improvements in operations, the system itself was an innova­
tion that provided competitive advantage over other firms in
the automobile production industry.
Another methodology that provides incremental improve­
ments, through reduction in defects and quality improvement,
is Six Sigma, originally developed by Motorola. Using the
DMAIC model of Define, Measure, Analyze, Improve, and
Control, experts (known as Black Belts, Green Belts, and
Yellow Belts, depending upon level of training and responsi­
bility) attempt to improve the quality of process outputs by
minimizing variability in the production line and reducing
defects or errors to less than 3 per million (6 standard devia­
tions from the desired target, thus 6-sigma). Quality manage­
ment tools used to identify areas needing improvement
include business process mapping, cost–benefit analysis, criti­
cal to quality trees, Pareto charts, and SIPOC analysis (suppli­
ers, inputs, process, outputs, and customers). After determining
the root cause of defects or inefficiencies, Six Sigma experts
apply and test such interventions as contingency planning,
parallel processing, and workflow redesign to reduce defects,
improve quality, and maximize throughput. Although the
methodology of Six Sigma provides only incremental improve­
ment to inefficient systems and may, in fact, stifle “outside-of-
the-box” innovation, improvements in operational productivity
and quality may yield substantial financial rewards, in terms
of cost savings, company goodwill and branding, and cus­
tomer and employee satisfaction.
In service industries, the value chain can be strengthened
by not only focusing on quality but also stakeholder happi­
ness. In “Putting the service–profit chain to work”, Hesket
et al. describe a model of stakeholder satisfaction, in which
internal service quality yields employee retention and pro­
ductivity, which in turn drives up external service value,
securing customer loyalty and retention, which has direct
impact on revenue growth and profitability.20 Employees and
consumers can move from a zone of indifference to zones of
affection or defection, depending upon their level of satisfac­
tion. In fact, Jones and Sasser argue, in “Why satisfied custom­
ers defect,” that complete customer satisfaction is the key to
securing loyalty – intent to repurchase – and generate superior
long-term financial performance.21 Different industries have
different loyalty/satisfaction curves, creating a mixture of
consumers that includes apostles, loyalists, mercenaries,
defectors, hostages, and terrorists. Companies should direct
efforts at achieving complete satisfaction to retain the loyalists
and attract the mercenaries (the apostles will stay), while the
BOX 5.6  Idea watch: service operations
Reference: Porter ME, Lee TH. The strategy that will fix health care.
Harvard Business Review. 2013;91:50–70.70
Perhaps the industry with the most potential, and most need, to
improve its performance is healthcare. The combination of rising
costs, uneven quality, limited access, and disparate outcomes has
led to a crisis in which the health of our economy, and our nation, is
at stake. Michael Porter is calling for a fundamentally new strategy.
Previous efforts, such as changing public policy, improving patient
safety, implementing evidence-based guidelines, involving patients
as consumers, reducing fraud, and implementing electronic health
records, have yielded small, incremental changes, at best. Instead,
value must become the overarching goal.
Transformation to a high-value healthcare delivery system must
involve the simultaneous cooperation of administrators, providers,
patients, health plans, and employers, to deploy the following
strategic agenda:
• Organize into integrated practice units
• Measure outcomes and costs for every patient
• Develop bundled prices for care cycles
• Integrate care delivery systems
• Expand areas of excellence across geography
• Build and exploit an enabling information technology platform

53
Innovation
improvement and value-added upgrades in technology. By
having a diverse portfolio of new products, Apple is ensuring
the success of its company, similar to a mutual fund with
multiple investments. Occasionally, such innovation is dis­
ruptive, displacing some products, increasing competition
with a company’s own products, and creating new markets
for other entrants. Such is the case with digital music; Apple
changed from a computer company to an information and
communications company, within a decade. Apple was able
to apply breakthrough technology to create new products. If
Apple had focused on incremental improvements in their
operating system or software, as Microsoft has done, then
such spinoff applications as e-books, online newspapers, and
of course iTunes might not yet exist. The real challenge will
come from Google, which started as a search engine but now
intends to dominate the landscape of cloud computing.
Three drivers of successful innovation are understanding
the consumer, “crossing the chasm”, and managing failure. To
succeed over a long-term horizon, companies need to serve
and retain their existing customers and acquire new ones by
applying incremental and disruptive technologies. The focus
of any commercial venture should start with the voice of the
customer – listening to what the customer wants – and should
finish with what the customer needs. Good marketing may be
able to identify needs that do not yet exist, or segments of the
population that have not been identified. Second, anticipate
who will need the product or service, and when. Prototypes
and early versions (think iPhone v1.0) are critical in attracting
the innovators (our medical students) and early adopters (our
residents), who will demonstrate product viability and create
an early buzz. Return on investment, however, will not occur
until the early majority (me) and late majority (my boss)
adopts this technology. Even laggards, who usually resist new
technology, may be an attractive group to target, as they may
become the early adopters of the next technology. Crossing
this chasm, from early adoption to market penetration, is
where most companies fail. The third component of successful
innovation, then, is learning from failure and managing
failure. Just as lean manufacturing and Six Sigma permit
and marketing, because these create real value; all other pro­
cesses are costs.22 Since the business environment is always
changing, the position of a company, relative to its competition,
new entrants, substitutes, suppliers, and consumers, is also in
flux. A company that enjoys dominant market share today
could become easily displaced tomorrow. Apart from innova­
tion, the only competitive advantage that a company can
maintain is based upon incremental improvements in price,
quality, and access – until a new company introduces an inno­
vation that dramatically affects these qualities, significantly
expands the size of the market, or actually changes customer
needs and preferences. Innovation is most effective and needed
during periods of stability, whereas process improvement is
most valuable to a company during periods of growth.
Successful innovation requires discipline and hard work,
in addition to creativity. Companies that have mastered the
process of innovation, such as Apple, Mayo Clinic, and the
design firm Ideo, follow a roadmap that consists of four
phases: breakthrough or discovery, platform development,
derivative changes, and maintenance. Through a carefully
orchestrated plan, in which these phases overlap, project
managers allocate resources (time, money, people) based
upon importance of each phase, level of uncertainty, and
location in the critical pathway. Apple may introduce a new
product, such as the iPod, iPhone, and iPad every few years,
but each of these devices undergoes an iterative process of
BOX 5.7  Idea watch: innovation
Reference: Christensen CM, Raynor M, McDonal R. One more time:
what is disruptive innovation? Harvard Business Review.
2015;93:44–53.71
Two decades after introducing the theory of “disruptive
innovation”, Clayton Christensen and colleagues set the record
straight. While disruptive innovation has proven to be a powerful
way to fuel innovation-driven growth, not all innovation is disruptive,
and certainly not all disruption is innovative.
The authors remind us, “disruption describes a process whereby
a smaller company with fewer resources is able to successfully
challenge established incumbent businesses . . . which focus on
improving their products and services for their most demanding
(and usually most profitable) customers” – exceeding the needs of
some segments and ignoring the needs of others. Uber, for
example, is clearly transforming the taxi business, but its financial
and strategic achievements do not qualify the company as
disruptive. According to Christensen’s theory:
• Disruptive innovations originate in low-end or new-market
footholds
• Disruptive innovations don’t catch on with mainstream
customers until quality catches up with their standards.
Although Uber has increased total demand in the taxi sector
– because the company developed a better, less expensive solution
to a widespread customer need – Uber did not start in low-end or
unserved markets. Instead, Uber created sustaining innovations that
actually improve the taxi business, such as booking rides on a
smartphone app, using GPS to reduce wait times, offering cashless
payments, and providing passengers and drivers with the ability to
rate each other. Furthermore, Uber uses a variable pricing algorithm
that usually results in a less expensive ride, which is more punctual
and reliable than traditional taxi services. An area where Uber may
truly produce a disruptive innovation is the application of this
technology to ride-sharing and car-pooling, as an alternative to our
solo commutes to work.
Fig. 5.3  Innovation: incremental change in breast reconstruction.
Most demanding use
Medium quality use
Autologous tissue
Alloplastic materials
Low quality use
High quality use
Performance
Fat grafting
Time
Breast reconstruction as a model for innovation
Disru
ptive
techn
ology

54
CHAPTER 5 • Business principles for plastic surgeons
Fig. 5.4  Innovation: disruptive change in breast reconstruction.
pTRAM free TRAM MS TRAM DIEP SIEA
Internal prosthetics SSM/SLNBx Cohesive gel Bioscaffolds
External prosthetics
Latissimus flap and implant SSM/SLNBx Cohesive gel
Performance
Disru
ptive
techn
ology
Most demanding use
Medium quality use
High quality use
Low quality use
Fat grafting
Time
Breast reconstruction as a model for innovation
incremental improvement in production systems, controlled
experimentation increases the yield of innovation efforts.
Measures to minimize risk include separation of invention
from execution, maintaining a diverse and deep pipeline of
ideas and projects, and collaborating with people outside of
your area of technical expertise or “comfort zone”.
In the field of plastic surgery, breast reconstruction has
experienced both incremental and disruptive innovation,
involving alloplastic materials that continue to be refined
(silicone and saline implants), as well as surgical methods
that utilize vascularized tissue (latissimus, transverse rectus
abdominis myocutaneous (TRAM), and perforator flaps). The
recent introduction of fat grafting, initially used to correct
contour deformities, may actually supersede conventional
methods of reconstruction, to become a primary method of
breast replacement (Figs 5.3 & 5.4). In addition to such factors
as durability and cost of reconstruction, the value chain will
also need to incorporate patient and provider preferences,
until a new market equilibrium is established.
Entrepreneurship
“The people who get on in this world are the people who get up
and look for the circumstances they want, and, if they can’t find
them, make them.”
George Bernard Shaw
Whereas technology is the way that you do things and inno­
vation is the way you do new things, entrepreneurship (Box
5.8) is the way that you increase the value of what you do.26
Entrepreneurship is a way of thinking, as well as a process,
that increases the impact of innovation. An entrepreneur
articulates a vision and develops a system that assembles
inputs, creates a product, service, or information, and cap­
tures new value from the outputs. Entrepreneurial leaders
act to bring a future business possibility into existence, with
a sense of urgency, not constrained by limitations in capital,
personnel, or productions. Instead, the entrepreneur utilizes
his or her imagination, drive, passion, and networking,
to gain the support of investment bankers, suppliers,
and customers.
Perhaps the most important resource to an entrepreneur,
though, is an asymmetry of knowledge. Entrepreneurs may
be aware of: 1) macro-economic forces yielding change in
demographic, social, and cultural norms; 2) new technologies
without defined applications; and 3) existing inefficiencies
embedded within current industries. Such incongruities, in
the setting of new technology and changing markets, repre­
sent tempting opportunities for entrepreneurs. Good entre­
preneurs find opportunities; great entrepreneurs make
opportunities. One example of capturing latent value in
healthcare is to move ambulatory services out of the hospital,
which carries a high overhead burden, and into ambulatory
settings, where overhead costs are lower, and variable direct
costs can be more accurately measured and controlled. An
accredited, office-based surgery facility may actually improve
quality and safety, in addition to decreasing the cost of care
and improving patient satisfaction (Figs 5.5 & 5.6). Moving
Fig. 5.5  Entrepreneurship: location of services, volume, and revenue. ASC,
ambulatory surgical center; ED, emergency department; OR, operating room.
Collections
Procedure location, volume, revenue
ED
Expenses
Office
OR
ASC
OR
Hand aesthetic
Breast recon
Hospital
OR
Microsurgery
Body contouring
Facial fractures
Burns
Clinic

55
Entrepreneurship
the correct activities to the most appropriate location makes
sense, creates value, and improves the patient–provider
experience.
What is the process, then, for turning a challenge into an
opportunity? The first and single most important act is to
establish a value proposition, which can be defined as that core
competency which makes your product or service unique and
valuable. The value proposition presents a problem and solu­
tion, describes what you do and how you do it, and serves to
differentiate you from the competition – all in one sentence.
From this value proposition, the entrepreneur next develops
a business model, which must then be translated into a busi­
ness plan. The addition of a marketing plan, financial pro
formas, and an operations template helps the entrepreneur
create a true value-chain, mapping out the process path of the
product or service (Fig. 5.7). These elements are linked by
strategy, which describes how to achieve the value proposition,
or specifically, how the product or service will reach the initial
beachhead segment and possibly penetrate the general market
(Fig. 5.8). Leadership serves as the cohesive force that manages,
directs, and grows the entire enterprise. Leaders must fulfill
the value proposition and ensure that the mission, vision, and
values of the enterprise remain consistent and virtuous.
With details carefully thought out and available to potential
stakeholders, the entrepreneur must seek support for this plan
Fig. 5.6  Entrepreneurship: effect of shifting location of care. ASC, ambulatory
surgical center; ED, emergency department; OR, operating room.
Collections
ED
Expenses
ASC
OR
Body contouring
Facial fractures
Office
OR
Burn recon
Aesthetic breast recon
Hand
Hospital
OR
Microsurgery
Acute burns
Clinic
Procedure location, volume, revenue
Fig. 5.7  Entrepreneurship: aligning the elements of a new venture.
Value
proposition
Strategy
operations
Business
model
Financial
model
Marketing
Fig. 5.8  Entrepreneurship: linking the elements of a new venture.
Value proposition
Innovation and core competencies
Mission and vision
Beachhead
segment
Barriers
Sustainability
Exit plan
Planning
Implementation
People
Resources
Value chain
Patient throughput
Project management
Situation analysis
Environment
Trends
Competition
Alliances
Marketing mix
Product
Price
Promotion
Positioning
Strategy
Business
model
Financial
model
Operations
Marketing
Income statement
Balance sheet
Debt and equity
Cash flows
Service description
Revenue streams
Variable costs
Overhead
through different types of communication. The elevator pitch,
which is a 30-second distillation of the new venture, is
designed to attract interest and pique the listener’s curiosity.
The executive summary is a one-page summary of the busi­
ness plan, whereas the business plan is a highly detailed
document, ranging from 20 to 60 pages, designed to address
specific questions, as investors look further into the venture.
A ten-minute overview, typically delivered as a PowerPoint
talk, is also necessary to get investors to actually read the
business plan.
At every stage, the entrepreneur seeks to increase the inter­
est of potential stakeholders and actively listens to feedback,
so that the business plan can be revised, rewritten, and refo­
cused, as often as needed. If the entrepreneur can gain the
commitment of the stakeholders, then begins the process of
raising capital, carefully managing cash, and coordinating
logistics. Entrepreneurs typically bootstrap for as long as they
can, utilizing human, intellectual, and social capital, rather
than borrowing money or seeking outside funding. Entrepre­
neurs know that that worst time to raise money is when they
absolutely need it, because they must cede control and owner­
ship of the company, each time investors are brought on board
with an influx of capital. Venture capital is particularly chal­
lenging to accept, because these investment bankers demand
a 5–7× return on their investment, within a time horizon of
several years, and because their exit strategy is ultimately
about sale of the company, not necessarily growth of the
company. Angel investors, friends and family, philanthropy
and endowments, academic and community grants, small
business loans, and even credit cards are more attractive (but
limited) sources of capital, permitting the entrepreneur to
retain control as long as possible. Finally, the cost of capital is
highest at the beginning of the venture, because the risk is
greatest, and borrowing costs decrease as the venture becomes
more successful.
Writing a business plan is an art that entrepreneurs must
master. Fig. 5.7 depicts a model that can be used when design­
ing the elements of a new venture. Much like writing abstracts
and journal articles, repetition improves the quality of the
product. But unlike scientific papers, which are published

56
CHAPTER 5 • Business principles for plastic surgeons
once and do not change, business plans are living documents
that are constantly in flux and mandate frequent update.
Nevertheless, a typical business plan follows an established
model and contains the following components:
1. Executive summary
2. Value proposition
3. Vision, mission, values statement
4. Marketing analysis
a. Situation analysis
i. Environment
ii. Trends
iii. Company analysis
iv. Competition
v. Alliances
b. Target market and segmentation
c. Positioning and differentiation
d. Channels
e. Branding
f. Sales tools
g. Marketing budget
5. Business model
a. Description of service or product
b. Revenue streams
c. Variable costs
d. Overhead and fixed costs
6. Strategy
a. Beachhead segment
b. Value chain
c. Growth
d. Response to competitors, new entrants, substitutes
7. Governance and management teams
8. Financial pro formas (typically 3–5 years)
a. Income statement
b. Balance sheet
c. Cash flows: operations, financing, investments
d. Time to break-even
9. Debt and equity structures
10. Operations
a. Planning: Gantt chart
b. Implementation
c. Throughput assessment
d. Continuous improvement plans
11. Legal and regulatory issues
12. Sustainability practices (triple bottom line of people,
planet, profit)
13. Barriers and roadblocks
14. Contingency plans
15. Exit strategy
Eventually, the CEO entrepreneur, having built a successful
company, must make some major decisions, beyond resource
allocation and management of revenue streams. In the short
run, the leader will need to delegate operational decisions,
while he or she focuses on setting strategy, team building,
establishing culture, and reinforcing vision and values. Ulti­
mately, however, the entrepreneur may recognize an internal
calling to cede control, so that he or she can begin the process
again, with a new idea, perhaps in a new industry, with a new
market. Others, however, remain with the company as a
technical advisor or may serve on the Board of Directors,
content with knowing that despite great odds, they created
something of value. To paraphrase Steve Jobs, they “put a
ding in the universe”.
Sustainable enterprise
“If you want to go fast, go alone. If you want to go far, bring
others with you.”
African proverb
Sustainable enterprise (Box 5.9) is a well-established concept
that has recently caught the attention of academics in organi­
zational behavior, business executives, supply chain manag­
ers, shareholders, and even consumers.27–34 The importance of
sustainable enterprise is so great that specific companies, as
well as entire industries, are reassessing their vision and
values, so that organizations can meet a new triple bottom
line of “people, planet, and profit.” Green business, or sustain­
able enterprise, produces no or little negative impact on global
or local environments, the community, society, or the economy,
with specific attention to progressive human rights and envi­
ronmental policies.
Previous efforts toward “reduce, reuse, recycle, repair, and
redistribute” have been replaced by more aggressive attempts
to minimize the carbon footprint of a business, search for
renewable energy sources, and lessen the impact of waste
materials on the environment, with the goal of establishing a
BOX 5.8  Idea watch: entrepreneurship
Reference: Isaacson W. The real leadership lessons of Steve Jobs.
Harvard Business Review. 2012;90:92–102.72
Walter Isaacson, former CEO of CNN and author of best-selling
biographies on Benjamin Franklin and Albert Einstein, and Steve
Jobs, identifies the practices every CEO can try to emulate.
Isaacson writes of Jobs: “His saga is the entrepreneurial creation
myth writ large.” By transforming seven industries (personal
computing, animated films, music, phones, tablet computing, retail
stores, and digital publishing), Steve Jobs will be remembered not
for his personality, but how he applied imagination to technology
and business. Jobs succeeded by pursuing the following practices:
• Focus
• Simplify
• Take responsibility end to end
• When behind, leapfrog
• Put products before profits
• Don’t be a slave to focus groups
• Bend reality
• Impute
• Push for perfection
• Tolerate only “A” players
• Engage face-to-face
• Know both the big picture and the details
• Combine humanities with the sciences
• Stay hungry, stay foolish
I would add, “Think different.”

57
Human resource management
progressive economist at Columbia University, and Muham­
mad Yunus, winner of the Nobel Peace Prize for his work on
microfinance in India, both contend that we have both the
resources and technology to end extreme poverty during our
lifetimes. Part of the answer to eradicating extreme poverty is
improving the health of those 2.5 billion people who exist at
the “bottom of the pyramid” (individuals who live on less
than $2.50/day). Optimizing global health is possible with
improved water purification systems, agricultural alliances
to improve supply chain logistics, regulation of markets to
eliminate corrupt middlemen in local markets, access to
medical supplies such as antibiotics and antiretrovirals, and
establishing microcredit and microloans. Once again, sustain­
able health endeavors are not only desirable from an ethical
perspective, but such ventures can open new markets and
new opportunities for investment.
Human resource management
“A small group of thoughtful people could change the world.
Indeed, it is the only thing that ever has.”
Margaret Mead
Perhaps one of the most important, least appreciated, and
often neglected components of business administration is
human resources management (HRM) (Box 5.10), which can
BOX 5.9  Idea watch: sustainable enterprise
Reference: Porter ME, Kramer MR. Creating shared value. Harvard
Business Review. 2011;89:62–67.73
Having developed the concept of the value chain, as it relates to
the creation of value along the supply chain, Michael Porter now
proposes that value created should be shared with the society. Not
only does this fulfill the social responsibility of the enterprise, but
this may also be really good for business, with the power to unleash
the next wave of global growth. Porter argues that societal needs,
not just conventional economic needs, define markets, and social
harms can create internal costs for firms.
Porter defines “shared value” as policies and operating practices
that enhance the competitiveness of a company while
simultaneously advancing the economic and social conditions in the
communities in which it operates. Shared value creation focuses on
identifying and expanding the connections between societal and
economic progress. Shared value occurs by reconceiving products
and markets and by redefining productivity in the value chain. For
example, a company can address specific social concerns, such as
water and energy use, employee health and worker safety,
environmental impact, and supplier access and viability, as they
relate to the specific products or services that the company
produces. Whereas corporate social responsibility (CSR) is pursued
separate from strategy and is determined by external pressures of
sustainability, philanthropy, and citizenship, creating shared value
(CSV) aligns social and economic needs to compete more
effectively and to maximize profits. CSV is based on a company-
specific agenda, internally generated, to realign the strategy of the
entire enterprise.
Porter believes that CSV represents the evolution of capitalism,
entirely consistent with Adam Smith’s “invisible hand.” Shared value
benefits both the community and the enterprise. This self-interested
behavior yields profits that create social benefits, rather than
diminish them. Economic value is created by the commitment to
generating social value.
business that meets the needs of the present, without compro­
mising the ability to meet the needs of the future. Specific
examples of sustainable business practices include telecom­
muting, having a paperless office, minimizing shipping
and packing material, leasing equipment that can be returned
and refurbished, lean production methods which utilize
less raw materials and produce less inventory, continuous
improvement processes in the supply chain, and conducting
business in LEED-certified buildings, which have lower
energy requirements and are made of post-consumer materi­
als. Products of service are durable goods that the manufac­
turer plans to re-process (thus the term “cradle-to-cradle”
when describing the responsibility of the manufacturer), and
products of consumption are short-lived materials that are
non-toxic and biodegradable.
These sustainable business practices have coalesced into
the more formal principle of corporate social responsibility, in
which self-regulation is integrated into the overall business
model of a company or industry. Businesses have discovered
that sustainable practices can generate lasting value to share­
holders and stakeholders, in terms of quality, access, and cost
of services and goods. Such leaders as Ikea, Nike, Ford, and
even Wal-Mart have been able to reduce expenses, minimize
risk, increase revenues, and create stronger brands by build­
ing environmental and social thinking into their business
strategies. Most large companies now have a Chief Sustain­
ability Officer and publish an Annual Sustainability Report
that corresponds to the Annual Financial Report.
What can we do in healthcare, and specifically plastic
surgery, to leverage green practices and improve our triple
bottom line? Interestingly, plastic surgery has been a leader in
social justice for decades. Mission trips to developing nations,
in which specialized services are provided and re-usable
equipment is donated, has been a focus of many plastic sur­
geons, who could have spent more time in their private
practices and generated more money for their businesses.
What is especially admirable, in terms of sustainability, is the
effort to teach these surgical techniques to providers in devel­
oping nations, so that infrastructure is developed and conti­
nuity of care is established, between visiting groups and the
local communities. For surgeons who do not travel outside of
the United States, multiple opportunities exist within our
borders to establish similar exchanges, which can include
work done at Native American reservations, in underserved
areas like Appalachia, or at a community clinic. Even main­
taining on-call emergency department privileges, performing
lower-reimbursing reconstructive surgery, and assuming
some indigent care all count as sustainable efforts, as the
surgeon is contributing to a triple bottom line that does not
neglect the needs of his or her local community. Such volun­
teerism is sustainable enterprise and should be a goal for all
who practice this craft.
Healthcare, in general, has lagged behind other industries,
in terms of sustainable business practices. One definition for
sustainable medicine is the improvement of health within the
natural life cycle, which seeks to avoid strain on social, envi­
ronmental, and economic systems, so that new technologies
can benefit all people within a community, not just those
who can afford it. Extending this definition to the entire
population of our planet, we have a moral obligation to
provide basic healthcare to all, in the form of clean water,
food, vaccinations, and preventive medicine. Jeffrey Sachs, a