Reoperative Aesthetic & Reconstructive Plastic Surgery

26
PART I
THE R EOPERATIVE ENVIRONMENT
ASYMMETRY
Except in the case of midline scars, surgery almost always produces some degree of
asymmetry. Many reoperative procedures are aimed at addressing persistent or re-
current noticeable asymmetry. The asymmetry may be the result of malaligned or
misplaced scars, inadequate insetting or shaping of transferred tissue, or denervation
and atrophy.The asymmetry may be static or dynamic, as in the case of facial paral-
ysis.
Consideration of asymmetries must be factored into the planning of
any secondary operation to prevent unsatisfactory aesthetic results and
patient disappointment.
This 57-year-old woman had a previous upper and lower lid blepharoplasty and de-
sired additional periorbital improvement. Preoperatively she had upper eyelid asym-
metry with more fat removal on the right than on the left. Following endoscopic
brow lift (right) the upper eyelid asymmetry is unmasked and is considerably worse,
even though no surgery was performed on the upper eyelid. The patient was un-
aware of the asymmetry preoperatively but became exceedingly unhappy with her
appearance postoperatively. This case illustrates the importance of careful review
of preoperative photographs so that asymmetry can be discussed with the patient
preoperatively to avoid an unhappy outcome.

27
Chapter 1
What Is Reoperative Plastic Surgery?
WOUND HEALING CONSIDERATIONS
IN REOPERATIVE SURGERY
Reoperation implies incision or dissection through tissue that is in some phase of
wound healing. Depending on the time elapsed between the primary surgery and
the reoperation, one might encounter tissue in stages ranging from dense hemor-
rhagic scar to lmy, almost normal tissue planes.
A knowledge of the events associated with the normal sequence of wound healing
is helpful to understand the types of tissue that might be encountered during reop-
eration; how the need for reoperation may be precipitated by a failure of wound
healing;if possible, when best to plan secondary surgery;and special considerations
for reapproximating the wound.

28
PART I
THE R EOPERATIVE ENVIRONMENT
INFLAMMATORY PHASE
The early events of wound healing consist primarily of coagulation and in amma-
tion. Platelet aggregation is stimulated by the exposure of platelets to collagen and
the subsequent release of adenosine 5 -diphosphate (ADP), which in turn causes
the aggregation of additional platelets. Fatty acids from injured cells also contribute
to the stimulation of platelet aggregation. Both intrinsic and extrinsic coagulation
cascades ensue, resulting in the production of a brin scaffolding.
Activated aggregated platelets release locally active growth factors. The comple-
ment cascade then follows, causing increased capillary permeability.This permeabil-
ity, which allows uid and cells to migrate passively into the extravascular space, is
an important part of the in ammatory response. The sympathetic nervous system
mediates an initial period of vasoconstriction followed by vasodilation through the
action of histamine, prostaglandins, and serotonin. Complement factor C5a is one
of the most important chemotactic agents for the extravasation of neutrophils,
macrophages, and lymphocytes. Neutrophils enter the wound within hours after in-
jury.They release lysosomes, which in turn increase capillary permeability and con-
tribute to the phagocytosis of tissue particles and bacterial remnants. Macrophages
become activated by cytokines and also participate in the cleanup process.
Macrophages gradually predominate over the neutrophil population in the in am-
matory response and become the essential cellular element of wound healing. By 72
hours after injury the basal layer of the skin at the wound margins begins to
thicken. Fibroblasts begin to accumulate and proliferate.
LYTIC PHASE
During days 2 through 14 following wounding a lytic phase occurs.3 This phase is
the result of the action of lytic enzymes plus the release of lysosomes from leuko-
cytes, which soften the surrounding ground substance. In addition, broblast and
endothelial buds initiate brinolysis. The wound develops a central zone of hyp-
oxia surrounded by a zone of hyperoxia and vasodilation. Neutrophils are sensitive
to the low PO 2 in the wound center and to the acidic environment, which cause
them to disintegrate and release lysosomes. The collagenase from the lysosomes
helps to dissolve the collagen at the wound edges.
FIBROPROLIFERATIVE PHASE
The lytic phase is followed by a phase of active cellular proliferation during which
angiogenesis and epithelialization occur.The events associated with the active pro-
liferative phase are the appearance of various substrates required for wound healing,
including proteoglycans and glycosaminoglycans, which seem to have a structural
and regulatory role in the wound healing process.4 The level of hydroxyproline
also becomes elevated to ve to six times the baseline value.

29
Chapter 1
What Is Reoperative Plastic Surgery?
Capillary budding occurs along breaks in the basement membrane; each solid
sprout then develops a lumen as the endothelial cells migrate to and surround it.
Certain angiogenic factors appear to control this process, including acidic bro-
blast growth factor (a-FGF),basic broblast growth factor (b-FGF), and angiotensin.
These new capillaries convey oxygen and substrate, eventually linking up with each
other and bridging the approximated wound. If the wound is left open, the capil-
laries form the delicate pink structure of what is referred to as granulation tissue.
Granulation tissue will readily accept a skin graft, because the capillaries link directly
with those in the graft.
Epithelialization rst occurs at the wound. Cells begin to elongate and migrate
within the rst 24 hours after injury. By 72 hours, increased mitotic activity is ev-
ident in the basal layer. When the advancing cells from both sides of the wound
meet, differentiation into a mature, layered structure of skin begins to occur. How-
ever, the rete pegs of mature skin do not develop in areas where the basement
membrane has been lost.
COLLAGEN FORMATION
Central to the wound healing process is the formation of collagen. Platelet growth
factors such as platelet-derived growth factor (PDGF) and transforming growth
factor-beta (TGF-beta) stimulate the differentiation of pluripotential perivascular
mesenchymal cells. Some of these cells evolve into collagen-producing broblasts
and others become myo broblasts, the cells responsible for wound contraction. En-
dothelial cells promote this response by inducing brinolysis ahead of these mi-
grating mesenchymal cells.
Several different forms of molecular collagen exist. The most common, type I, is
widely distributed through bone, tendon, skin, dentin, ligaments, fascia, arteries,
and the uterus. Skin is also relatively high in type III collagen.Types II, III, and IV
are found in cartilage, arteries, and basement membrane. In the proliferative phase
of wound healing, early collagen synthesis results in small, less-well-organized -
brils rather than mature collagen bundles.These brils cross-link in the rst 4 to 6
weeks following injury to obtain the strength and organization of mature colla-
gen. However, scar collagen remains relatively irregular, with thinner collagen fas-
cicles.This pattern is thought to be related to the types of glycoproteins present in
the ground substance. Normal skin contains both type I and type III collagen in a
ratio of approximately 4:1. However, in hypertrophic or immature scars, the relative
amount of type III collagen may rise to 50% of the total.
MATURATION PHASE
The nal phase of wound healing is the maturation phase; this phase overlaps the
proliferative phase.3 During maturation, the immature collagen brils increase their
degree of cross-linking and therefore increase the tensile strength of the wound.

30
PART I
THE R EOPERATIVE ENVIRONMENT
Similarly, the cellularity of the wound and collagen solubility diminish.The wound
achieves 25% of its ultimate strength by 24 days after injury. Fifty percent is achieved
by 50 days, with maximal strength attained by approximately 1 year. However, even
when fully mature, the scar will have only approximately 80% of the normal ten-
sile strength of unwounded skin. By 2 to 3 months after wounding, collagen de-
position is gradually overtaken by collagen degradation, resulting in extensive re-
modeling of the scar. This remodeling process is continuous for approximately
1 year.
IMPLICATIONS FOR THE R EOPERATIVE SURGEON
If a fresh wound must be opened between 24 and 48 hours after injury, a brin seal
between the cut surfaces is encountered. The surrounding tissues are edematous
and thickened from the cellular proliferative response. Collagenolysis at the epithe-
lial edge of the wound weakens the connective tissue, which means that sutures
may pull through more easily with considerably less tension than normal.
Reopening a wound during the rst 3 to 4 days after injury is generally easy and
does not require reincision but simply blunt dissection. However, after this period,
the effects of the intense angiogenesis and neovascularization are noted on dissec-
tion.The dilated venules and capillary buds will freely bleed.
During the lytic phase (days 2 through 14), the wound is at its weakest as a result
of the lysosomal activity at the wound margin. Surgeons have long recognized that
problems such as abdominal dehiscence and the development of an orocutaneous
or intestinal stula are most likely to appear around day 7 following injury. How-
ever, this weak state can persist for as long as 3 weeks. When reclosing such a
wound, one must be aware that this zone of weakness is present at the wound mar-
gins. In regions where the tissues are thick and heavy, such as the abdomen, sutures
must be placed outside this zone at least 1.5 cm from the wound margin to achieve
satisfactory tensile strength to maintain the integrity of the closure. In the face, the
sutures may be within 1 cm of the skin edge.
It is also important to keep in mind that when a 7-day-old wound is reopened and
then reclosed, this action does not convert the wound to the state it was in during
the rst 24 hours of wound healing. All of the cellular populations that were called
forth are still present, and the biochemical events that took place have not been
reversed.Therefore continued healing proceeds directly at what appears to be an ac-
celerated pace. The increased collagen synthesis present in the wound during the
proliferative and maturation phases can work to the surgeon’s advantage.With these
processes active at several times the normal rate, wound healing will advance di-
rectly and completely in a shorter period of time than after primary wounding,
when the in ammatory phase must occur to incite the proliferative phase. It is for
this reason that a delayed primary closure appears to result in accelerated healing,

31
Chapter 1
What Is Reoperative Plastic Surgery?
especially if the wound itself is not reexcised during the debridement process.
Wounds closed in this way are ultimately no weaker than those closed primarily.
Reoperation during the proliferative stage of wound healing can be treacherous.
First, the tissues are noncompliant and weak because the collagen at the wound
margin is immature.Therefore attempting to place sutures in tissues of this type can
result in a failure of rm healing. For example, attempts to close an orocutaneous
stula or to resuture a ap intraorally may result in wound breakdown because the
sutures simply will not hold. Second, opening a wound during the proliferative
phase can result in profuse bleeding. Attempts to coagulate bleeding points will re-
sult in further injury and increased tissue destruction.
Wounds that are allowed to heal on their own are greatly aided by the presence of
myo broblasts at the wound margin.These specialized cells will persist in wounds
for up to 2 months. By forming intercellular attachments, myo broblasts, which
have properties similar to those of smooth muscle, create a line of contraction
around the edges of the wound. This process can result in a bandlike effect, espe-
cially in scars that cross exion creases. For this reason, scars of this type may need
to be excised to allow the surrounding skin to return to its normal position before
a closure method is designed that might result in an improved scar.
In terms of bleeding and dense adhesions, the worst time to reoperate on a patient
is early in the maturation phase of wound healing, between 20 and 60 days after in-
jury. Reentering the abdomen during that time will usually reveal dense, bloody ad-
hesions, and inadvertent enterotomy can occur easily. After 90 days, collagen re-
modeling and maturation have progressed to the point at which adhesions are
largely absent. Similarly, by this time the skin and subcutaneous tissues have be-
come soft and more pliable. Reoperation can thus be much more easily and safely
accomplished.
High collagenase activity at the margins of a scar or keloid has been used to advan-
tage during scar revision surgery. It is postulated that if a thin rim of previous scar
is left, the resultant scar may be thinner and of higher quality than if no previous
scar is left.5 More often, however, the presence of this previous tissue injury is detri-
mental to healing following secondary surgery.
Finally, the principles of good surgical technique assume a much more important
role in reoperative surgery. The plastic surgeon becomes an exceptionally good
judge of tissue tolerances by look and feel.The differences in tissue are explainable
on the basis of the orderly events of wound healing.When wound healing is inhib-
ited by such factors as poor nutrition, chronic disease, drugs, or radiation, then fur-
ther alteration of tissue quality is likely to be encountered (see Chapter 5). Gentle
tissue handling, sharp dissection, limited use of cautery, preservation of vascularity,
and careful reapposition of tissues without tension often can make the difference
between success and failure in reoperative surgery.

32
PART I
THE R EOPERATIVE ENVIRONMENT
References—With Key Annotated References
1. Broughton G II, Rohrich RJ.Wounds and scars. Select Read Plast Surg 10:7, 2005.
This publication discusses the phases, factors, and adjuncts of wound healing, including wound care,
closure, and dressings. A section on hypertrophic scars and keloids includes treatments both nonsurgi-
cal and surgical.The volume includes a section on exotic wounds.
2. Glat P, Longaker M. Wound healing. In Grabb WC, Smith JW, Aston SJ, et al, eds. Grabb and
Smith’s Plastic Surgery, Philadelphia: Lippincott-Raven, 1997.
This book explains the fundamental principles of plastic surgery and microsurgery and describes spe-
ci c aesthetic and reconstructive surgical procedures for various anatomic regions.
3. McQuarrie DG.The pathophysiology of wound healing and its relationship to reoperative sur-
gery. In McQuarrie DG, Humphrey EW, eds. Reoperative General Surgery. St Louis: Mosby,
1992.
This text covers all reoperations performed by general surgeons. Anesthetic concerns, reoperative vas-
cular surgery, reoperation after minimally invasive surgery, reoperations after severe, acute trauma, and
reoperation for necrotizing soft tissue infections are included.This text also includes advice for using
various diagnostic tools and nonoperative solutions.
4. Hopkinson I. The extracellular matrix in wound healing: An introduction to the series in
wounds: A compendium of clinical research and practice. J Wound Heal 4:88-91, 1992.
5. Peacock EE Jr,Van Winkle W Jr.Wound repair. Philadelphia:WB Saunders, 1976.

33
Chapter 1
What Is Reoperative Plastic Surgery?
1. The spectrum of reoperative surgery includes all of the following except:
a. Planned reoperation
b. Liposuction
c. Improving a less than satisfactory outcome
d. Re nements or touchups
e. Treatment of complications
2. The reoperative surgeon must assess:
a. The degree of anatomic distortion
b. The nature and consistency of the scar
c. The scope and condition of the involved anatomic area
d. The availability of healthy surrounding tissue
e. All of the above
3. Reoperative surgery differs from primary surgery because of all of the following
except:
a. Scarring
b. Asymmetry
c. Potential denervation
d. The need to obtain informed consent
e. Altered tissue characteristics
4. The worst time to reoperate on a patient because of profuse bleeding or dense
adhesions is during the:
a. Fibroproliferation phase of wound healing
b. Lytic phase of wound healing
c. Early in the maturation phase of wound healing (20 to 60 days after in-
jury)
d. During the rst 12 hours postoperatively
e. Late in the maturation phase of wound healing (greater than 90 days af-
ter injury)
5. The likelihood of success versus failure in reoperative surgery is increased by:
a. Gentle tissue handling
b. Limited use of cautery
c. Preservation of vascularity
d. Careful reapposition of tissues free of tension
e. All of the above
R EVIEW QUESTIONS

(Trang không có chữ)

35
The Patient
James C. Grotting
C ha pter 2
The patient is waiting in exam room 5. As I approach the door, I see a folder thick with
medical records, radiographs, and CT scans. Reading through these documents, I wonder what
kind of person is sitting inside. Will I be able to help him? Can I hope to accomplish some-
thing that the previous surgeon had not?
Reoperative patients’surgical history and past interactions with health care profes-
sionals set them apart from primary surgery patients and in uence how they re-
spond to the prospect of further surgery. As surgeons we have no way of predict-
ing this response.What is predictable, however, is that the patient’s focus will be on
the problem that requires reoperation. All that the patient knows is that something
is wrong:“It doesn’t look right” or “It doesn’t feel right.” He or she may not know
what went wrong or why, but just wants it “ xed.”The patient may desire a lengthy
explanation of all the factors contributing to the poor result or may simply want to
get on with the surgical correction.
Although some patients may appear to be uneducated, unsophisticated, or inca-
pable of fully understanding all of the considerations involved in a staged recon-
struction or the factors that can contribute to a less than satisfactory result, it is
generally a mistake to assume this is true. A patient usually appreciates all of the in-
formation the surgeon can provide, even if there is too much information to fully
assimilate or if the patient has crossed the line from active participation to blind
trust.
It is best to explain things simply but completely.
Making the same point several different ways at various times in the consultation
enhances the patient’s memory of the concept and avoids misunderstanding.

36
PART I
THE R EOPERATIVE ENVIRONMENT
THE REOPERATIVE ENVIRONMENT
The patient may require reoperation for one of the following reasons:
1. To proceed with a planned second or third stage of a reconstructive plan
2. To treat an early complication, perhaps one that developed before discharge
from the hospital or before primary healing has occurred
3. To treat a late complication that detracts from an otherwise good postoper-
ative result
4. To improve an initial result deemed suboptimal by either the surgeon or the
patient
5. To address biologic factors such as tumor recurrence or the effects of con-
tinued aging, despite a successful initial operation
The attitudes and psychological needs of the patient may be quite different in each
of these situations. Clearly, the patient requesting a secondary face lift 10 years af-
ter a successful rhytidectomy is not likely to have negative feelings about the pro-
cedure or toward the surgeon. Conversely, the hostility generated by an angry
young male rhinoplasty patient with an overresected nose can intimidate even the
most seasoned plastic surgeon.
Most patients feel vulnerable when facing reoperative surgery. They may feel that
they are dependent on the skills of the plastic surgeon and at the mercy of the
health care system.This sense of a loss of control may lead to resignation, anger, and
even hostility. Patients are often more fearful about the second operation than they
were about the initial surgery and frequently need more reassurance. They fear
more pain, further scars, additional complications, and undergoing general anes-
thesia.
Considerable time should be allocated to the care and counseling of the patient
with early unresolved problems or complications such as open wounds, immature
scars, or infection. A patient with these early problems tends to view his or her
doctor with distrust.We have all had patients who consult with us as a second plas-
tic surgeon before their original surgeon has even removed the sutures.
The most common reason cited by patients for changing physicians is
a perception that their plastic surgeon is uncaring or unavailable to
address their concerns.
This sentiment is echoed in statements such as, “My doctor did not believe me
when I told him I was having a problem,” or “I tried to call her at her of ce but she
wouldn’t return my calls.” The plastic surgeon who hopes that by ignoring the
problem it will disappear usually nds it has only been compounded, and, of course,
anger can assume a life of its own.1 The patient who feels abandoned may seek the

solace of an attorney, who will always make plenty of time for the patient to air
complaints.
Many times I have had the opportunity to see patients who have had procedures by
other plastic surgeons on referral from my own patients in the community. More
often than not, I have been able to reassure the patients that the concerns they have
are very real but can easily be addressed by their treating plastic surgeon. Simply by
spending a little time listening, I feel that I have been able to get them back on track
with their original plastic surgeon and have not ended up taking them on as pa-
tients in my practice. Listening, I feel, is an underrated skill. It is crucial in establish-
ing and maintaining a good doctor-patient relationship.
DEFINING REALISTIC EXPECTATIONS
Most patients consulting with a plastic surgeon for the rst time have misconcep-
tions about what a plastic surgeon can accomplish. It is astounding how many be-
lieve that plastic surgeons can completely remove scars or that various kinds of
plastics can be used to miraculously transform the way people look. It is the respon-
sibility of the surgeon to give each patient the opportunity to fully verbalize expec-
tations from an operation. Based on this information, the surgeon must then help
to bring the patient’s expectations into line with reality and dispel any misconcep-
tions. Nothing is as effective for convincing a patient that less than perfect results are
possible as a failed or poorly executed operation.
Patients who are counseled about the possibility of unsatisfactory re-
sults and the necessity for reoperation in advance will not be as trou-
bled by complications or by the need for nishing touches as those
who thought that their rst operation was supposed to be their last!
Well-prepared patients will be disappointed but not shocked if reoperation is nec-
essary.The patients may feel “unfortunate” but will also be aware that further treat-
ment will produce better results, and thus they will remain optimistic about the
future.
Realistic expectations about the outcome of an operation are even more important
for patients facing secondary surgery. Because they feel a little wiser now, they may
ask more questions, desire more information, and require more details about pos-
sible outcomes. Providing best case and worst case scenarios is key to establishing
realistic expectations in this group of patients. The surgeon should show photo-
graphs of average results, a result considered excellent, and a poor result as well.
The surgeon should outline a series of steps or timetables for managing an unto-
ward result or complication should it occur.
37
Chapter 2
The Patient

38
PART I
THE R EOPERATIVE ENVIRONMENT
COMMUNICATING WITH THE REOPERATIVE
PATIENT
Goldwyn2 aptly pointed out that if either the patient or the surgeon knew before
an operation that something was going to go wrong, neither would enter into the
contract! Unfortunately, it is usually in retrospect that we begin to understand how
suboptimal results might have been anticipated and avoided. When surgeons deal
with patients facing unanticipated secondary surgery to treat complications or to
improve less than optimal results, the following principles merit attention.*
Always tell the truth.
This maxim is of the utmost importance in dealing with the reoperative patient.
One must deal honestly with patients to gain their trust.The sooner the issues are
confronted, the healthier the relationship will be.
Do not deny reality when deformities exist.
The surgeon must acknowledge problems squarely and not dismiss even seemingly
minor complaints. If a revision could improve a small deformity, the patient should
be advised accordingly and offered a treatment plan. However, unrealistic expecta-
tions should not be fostered by stating that you can take an excellent result and
make it perfect. If the patient has a legitimate complaint or problem, the surgeon
must rst acknowledge the deformity, admit that the result is less than hoped for,
and begin to outline a plan. Correction of a problem should be planned as soon as
possible to ensure patient satisfaction. Although the timing for initiating the reop-
erative plan may need to be revised based on wound healing considerations, the act
of merely determining a timetable will instill con dence and help the patient to
understand what to expect.
It is human nature to instinctively turn away from an adverse outcome when it is
one that we have created ourselves. Conversely, when the problem was created by
another surgeon, we tend to be more critical. For our own adverse outcomes the
worst mistake one can make is to try to blame the patient. Yes, smoking plays a
role in wound healing, but it is not always the sole factor in a complication.The an-
gry patient will only become angrier when attacked by a plastic surgeon who is not
willing to take any responsibility for a poor result.
On the other hand, some patients may perceive a deformity that simply does not
exist.These patients must be allowed to verbalize their complaints, but there is no
reason to lend credence to an imagined deformity. One must never be tempted to
*Patients undergoing planned secondary stages or secondary aesthetic surgery years later are dis-
cussed elsewhere, since the issues are somewhat different.

try to correct a condition that cannot possibly be improved.This action will guar-
antee a dissatis ed patient later on.
Demonstrate that you are appropriately concerned about the patient’s
problem.
Patients merit our attention, respect, and sympathy. The surgeon should plan to
spend adequate time listening to the patient’s concerns. Each of the patient’s ques-
tions and concerns should be addressed seriously and truthfully. Being a good lis-
tener under these circumstances will often relieve the patient of considerable stress
and anxiety by allowing verbalization of these feelings. Anger and hostility, if pres-
ent, will then usually give way to collaboration.
Do not ignore pain, as it is often a mechanism by which patients express dissatisfac-
tion.We may feel that a patient who complains of pain well beyond the time frame
that we deem appropriate for a particular procedure is merely seeking pain medica-
tion or has a low pain threshold. However, it may be the only way that a patient can
open the door to a conversation about areas of dissatisfaction.The surgeon must try
to reach beyond the subjective pain complaints and elicit these important clues re-
garding the patient’s perception of the result. In other words, not every patient
complaining of chronic pain is malingering or trying to avoid a return to work.
Postoperative depression is common and may be unrecognized by the patient and
manifested by complaints of pain.
Discussing a less than satisfactory outcome with a patient has potential pitfalls, par-
ticularly if the patient was not adequately counseled preoperatively. It is important
to try to see what the patient sees. Usually he is concentrating on the mirror im-
age to make a determination about persistent deformity. For this reason photo-
graphically documenting and discussing preoperative asymmetry in advance is an
important part of the consultation. The preoperative photographs can then be re-
viewed with the patient postoperatively to help him to evaluate the outcome.
It is possible to create dissatisfaction by pointing out a minor aw that the patient
does not see at all. I well remember one patient who came for a follow-up visit 1
year after bilateral breast reconstruction. She was absolutely beaming over the result
and had been proudly showing herself to other women and potential patients in the
community. I made the mistake of pointing out to her that the nipple reconstruc-
tion had undergone considerable atrophy, losing more projection than I had antic-
ipated. This was something that she had not noticed and with which she had not
been concerned. However, from that day on, the loss of nipple projection became
the focus of our discussion every time she came to my of ce. I do not believe she
was ever entirely pleased with the reconstruction again.
39
Chapter 2
The Patient

40
PART I
THE R EOPERATIVE ENVIRONMENT
It is often helpful to attempt to evaluate the patient as if you were a casual observer
rather than a plastic surgeon:What is the most striking feature of the deformity? It
is possible to lose sight of the “big picture” after having performed multiple oper-
ations on a patient. Your priorities may not be those of the patient or his or her
friends and family. Ask the patient,“What is it about the problem that bothers you
the most?” and “If you could have only one thing changed or improved, what
would it be?” These types of questions will help you refocus your plan so that it is
more in line with the patient’s concerns.
Recently I saw a patient with face and neck burns whom I had treated 1 year ear-
lier. He had been undergoing a series of operations with expanded neck aps to
resurface his neck and jawline. His neck and lower face area actually looked quite
good, but for the rst time I suddenly realized that the most obvious deformity
was his badly burned ears. He agreed that this defect had been bothering him, but
he did not think anything could be done about it. From that point on, my recon-
structive plan addressed the correction of the more obvious deformities.
Certain problems may not be amenable to surgical improvement.The patient may
choose to forego surgery rather than have an operation for something that does
not bother him. For example, most plastic surgeons when confronted with this pa-
tient would immediately focus on the missing right breast. However, this elderly pa-
tient had been getting along quite well for many years following a modi ed radi-
cal mastectomy for carcinoma of the breast. In fact, the only problem that she had
was the fact that the external prosthesis required for symmetry was large, heavy,
and quite uncomfortable in the summertime.Therefore her perception of the prob-
lem was that her left breast was simply too large to match her prosthesis. Even af-

41
Chapter 2
The Patient
ter a discussion of the options available to her for a reconstruction, the patient did
not wish to undergo breast reconstruction but rather she simply preferred a reduc-
tion mammaplasty of the large opposite breast. This procedure was done on an
outpatient basis and resulted in a much improved quality of life for her.
THE FAMILY DYNAMIC
An operation on a loved one can represent a crisis for the entire family. If the pa-
tient undergoes an elective operation against the wishes of family members and
then suffers a complication or unsatisfactory result, family relationships can deteri-
orate precipitously.The patient may feel guilty about the decision to have the pro-
cedure, particularly if a family member paid for an aesthetic procedure that pro-
duced a less than satisfactory result. The patient may even construe these
circumstances as God’s punishment for having de ed the family. Financial consid-
erations may come into play. Reoperation may mean more time off from work,
loss of income, and additional expense, which may cause stress among family mem-
bers. Sometimes the surgeon may nd that facilitating family communication is
more crucial to a patient’s treatment and well-being than the operation itself.
It is helpful to have another family member present for the consultation. Many pa-
tients will not completely comprehend or remember the doctor’s explanations.
Family members can often help to later remind them of issues that were discussed
or to explain things that the patient did not understand. Likewise, having another
staff member in the examination room is good practice. Another staff member may
notice facial expressions or other nonverbal clues that the surgeon might miss that
indicate problems in family relationships or a lack of understanding on the part of
the patient. Furthermore, a nurse or other staff member can spend additional time
with the family answering questions in the surgeon’s absence. In addition, in the
event of litigation, the veri cation by an additional person that certain issues regard-
ing informed consent were fully discussed could make an enormous difference in
a courtroom.
I have the good fortune to work with of ce staff who are amazingly intuitive when
it comes to forecasting which patients will be “problem” patients. I always make
certain that the staff interact with potentially dif cult patients. A patient may behave
quite differently with members of the of ce staff when not in the surgeon’s presence.
He or she may provide clues that would in uence whether or not this individual
is considered a good operative candidate. Input from various members of the of ce
staff can also be exceedingly valuable in formulating the nal operative plan.

42
PART I
THE R EOPERATIVE ENVIRONMENT
OUTLINING THE PLAN
Trying to make a patient believe that a complication is minor by outlining an overly
simple treatment plan sets a potentially dangerous precedent that often leads to fur-
ther patient dissatisfaction. There is no quicker way to lose the trust and con -
dence of a patient than to trivialize the problem.
The plastic surgeon performing secondary surgery may feel pressured to cut cor-
ners because of nancial considerations. A patient who has just paid a considerable
sum of money for a face lift will be understandably upset when, to have a hema-
toma drained, he or she must pay an additional fee for the operating room and the
anesthesiologist. The surgeon who has not in advance discussed the possibility of
additional costs to treat a complication of this sort might be tempted to try to take
shortcuts to save the patient or himself this expense. For this reason, it is crucial to
establish nancial responsibility before a procedure rather than trying to address
the issue on a crisis basis.
The well-prepared patient has been informed about the range of ad-
verse outcomes and the costs of treating them.The well-prepared sur-
geon has thought about these issues well in advance and established a
plan for treating complications should they arise.
In the realm of cosmetic surgery, costs of initial treatment and those related to re-
operative problems can profoundly affect the doctor-patient relationship. In fact an
unplanned hospitalization following cosmetic surgery can generate huge expenses
that may well not be covered by the patient’s own health insurance. This is a fact
that is often not recognized nor addressed by either the patient or the treating
physician. However, when it occurs it can rapidly lead to a complete breakdown in
communication as the responsibility for payment of these expenses becomes a
source of contention. Litigation may ensue as patients seek to transfer responsibil-
ity for these costs back to the treating plastic surgeon, hospital, or other medical
staff. This can occur even in the absence of negligence or below-standard-of-care
treatment. By addressing these issues in advance or preparing for them by having a
plan in place, the surgeon can mitigate potential problems and reduce the likelihood
of an unhappy patient. Insurance to cover unplanned hospitalization following cos-
metic surgery is now available to address this issue.
For the patient who has had a series of surgical misadventures, the surgeon must ask
himself, “What are the factors contributing to these repeated problems?” Many
times a problem cannot be solved by further rearrangement of local tissues, and a
different course of action must be taken. In this situation, it is dif cult for the pa-
tient to accept that much of the previous surgery has accomplished nothing and
that the new plan may include additional risks. Nevertheless, it is certainly a worse
choice to pursue a course that is doomed to further failure.

43
Chapter 2
The Patient
THE PATIENT SEARCHING FOR ANOTHER
SURGEON
The patient needing reoperation usually chooses to remain under the care of the
initial operating surgeon. Even if a problem occurs months or years later, most in-
dividuals seek recommendations and care from their original doctor.
Patients switch surgeons for a variety of reasons.The change may be occasioned by
a practical reason, such as a move to a different location. More commonly, the pa-
tient loses con dence in his or her surgeon or feels that surgeon is incapable of
correcting a problem or treating a complication.The patient may see a second sur-
geon on the advice of an attorney or occasionally at the request of an insurance
company. At other times a plastic surgeon may suggest that the patient obtain a
second opinion or consult with a fellow surgeon. In each of these circumstances the
role of the second plastic surgeon is different. If you are meeting with the patient
at the request of another plastic surgeon, you must clarify whether that surgeon
intends to have you assume care of the patient or simply provide assurance to the
patient that the original treating surgeon is “on the right track.” The original sur-
geon should inform the consulting surgeon if he or she intends to cover the cost
of the consultation;otherwise, the patient must pay the cost and should be advised
as such. The original surgeon should send copies of the patient’s records for re-
view. If these records are not forthcoming, your of ce should contact the original
surgeon’s of ce to obtain the necessary medical records and information so that
an unbiased second opinion can be rendered.
If the patient has sought you out directly, then your approach will be ultimately in-
uenced by what the patient wants. However, you must ask yourself,“Do I have
skills that the original surgeon does not possess?”“What are the chances of avoid-
ing a further complication or less than optimal result with my plan?” As the second
surgeon, you have increased legal risks: it is usually the second surgeon who gets
sued rather than the rst. Despite this risk, most plastic surgeons are best served by
letting their surgical judgment guide them.
As a consultant, you must determine the patient’s motivation. Most patients are
genuine in seeking to have their problem corrected by a skilled and caring sur-
geon. Some, however, have no intention of undergoing further surgery and are mo-
tivated by the promise of a malpractice settlement or continued disability payments.
Certain patients may have a psychological need to remain disabled to maintain the
sympathy and attention of family and friends. In any event, your role as a consul-
tant is to guide the patient to an honest and reasonable second opinion.What the
patient does with that information is of his or her own choosing.

44
PART I
THE R EOPERATIVE ENVIRONMENT
SPECIFIC PROBLEMS
Human beings are complex, but patients often convey recognizable patterns of be-
havior.The reoperative surgeon should be alert to these behavior patterns and ad-
just his or her approach to the patient accordingly.
THE ANGRY PATIENT
As discussed earlier, a certain degree of anger is common in the reoperative pa-
tient.This patient is often looking for someone to blame for his or her misfortune,
and the surgeon, or in some cases other members of the health care team, are the
recipients. Some of the anger may be directed at the spouse or other family mem-
bers simply because they are not the ones with the problem.
The most effective way to deal with this situation is to allow the patient to vent this
anger and verbalize his or her feelings.The surgeon must help the patient to under-
stand that anger is a normal reaction. The surgeon and patient can then move on
and discuss a course of action. The patient who cannot move beyond the anger
phase may bene t from referral to a social worker, psychologist, or skilled member
of your of ce; sometimes an uninvolved nonthreatening third party is effective in
helping the patient to deal with this hostility. Eventually, with the establishment of
a treatment timetable, the patient redirects energy in a more constructive manner
and much of the anger will usually disappear.
THE DISSATISFIED PATIENT
Patients facing secondary surgery or reoperation of any type may have justi able
reason for dissatisfaction. The results may indeed be less than optimal. Unrealistic
initial expectations and incomplete preoperative preparation may also contribute to
patient displeasure.This sense of grievance can be compounded by factors such as
monetary considerations, particularly if aesthetic surgery has not been paid for in
advance. As the weeks and months following the operation go by and the patient
is still making monthly payments, the little things that otherwise might have gone
unnoticed or been ignored become a major focus of dissatisfaction; patients may
consider themselves continuing to pay for a deteriorating result! Occasionally the
patient will confront the surgeon and try to negotiate a new contract:“I don’t be-
lieve I should have to pay the balance of my bill because my breast lift no longer
looks as good as it did.” This situation is most awkward for the plastic surgeon,
who must then either press for payment or defer to a new arrangement merely to
avoid having to do a secondary correction gratis.
By reviewing the preoperative and postoperative photographs with the patient, of-
ten the surgeon can help the patient to appreciate improvements that the patient
may not recognize. People have short memories regarding certain deformities and
often simply forget how much they disliked the way they looked preoperatively.
Comparing the photographs may help them to feel good about themselves once

again. Conversely, if only modest improvements are appreciable when the photo-
graphs are compared, this observation may fuel the patient’s perception that the
expense outweighed the visible bene ts of the surgery.
Usually a reminder of the preoperative discussion of the various potential outcomes
will seem adversarial to the patient and will be counterproductive at this point.
Nevertheless, it may be worth mentioning the conversation to a patient who seems
to have completely lost memory of the preoperative counseling.
THE PATIENT W ITH A PSYCHIATRIC PROBLEM
Patients with psychiatric disorders are a potential problem for all plastic surgeons,
but particularly in reoperative situations. Patients with certain psychiatric disorders
who seek elective aesthetic surgery are often not helped by the surgery and may in
fact be harmed. One such disorder has been called body dysmorphic disorder
(BDD) (see Chapter 3) in which the patient becomes preoccupied with and grossly
exaggerates a slight physical defect.4 The disorder can profoundly affect the pa-
tient’s ability to function in a normal capacity. The patient might even imagine a
defect when in fact there is none. He or she might become obsessed with hiding
the deformity to the point that the patient will not venture outside the home.The
patient may go from surgeon to surgeon seeking to have the imagined defect sur-
gically treated. Depression can accompany this disorder.The most effective way to
screen for BDD is to conduct a careful and thorough patient interview. In this set-
ting the plastic surgeon can often pick up clues that will help to identify this type
of patient.When questioned about motivations for a particular procedure, the pa-
tient may exhibit behaviors that re ect an inappropriate concern about the defor-
mity. He or she may be unemployed or unmarried and causally link this situation
to the perceived defect rather than to other factors.3
Even though we can all think of patients who might t this BDD pro le, the spe-
ci c diagnosis of BDD may not be so straightforward4 (see Chapter 3). Many cos-
metic surgery patients do have some degree of preoccupation with appearance is-
sues that we might consider minimal or slight. It is quite common during cosmetic
surgery consultations to nd patients who use close-up mirrors and view them-
selves in certain lighting at odd angles to de ne concerns they have about their fa-
cial features. Certainly not all of these deserve a diagnosis of BDD. However, with
experience most plastic surgeons can recognize that ne line between appropriate
concern and dysfunction.
If this disorder is detected, the plastic surgeon might inquire as to whether the pa-
tient is currently under the care of a psychiatric professional. If so, the surgeon
should ask the patient to be allowed to speak with the psychiatrist regarding any
possible surgery. In addition, the surgeon should inquire if the patient is receiving
any kind of psychoactive medication; some types call for special consideration in
terms of anesthesia. If such a patient is not under the care of a psychotherapist, an
appropriate referral would be prudent before proceeding with any kind of surgery.3
45
Chapter 2
The Patient

46
PART I
THE R EOPERATIVE ENVIRONMENT
I recently saw a patient who had been turned down for secondary rhinoplasty by
5 other plastic surgeons. Although she exhibited obvious deformity that could have
been improved through surgery, she exhibited clear psychiatric disturbance that
made it dif cult to develop anything but an antagonistic doctor-patient relationship.
She rocked back and forth in her seat, repeating over and over again that she knew
that I would refuse to operate on her because of her race, even before I could out-
line possible surgical approaches for her. She threatened to bring an EEOC action
against us, all before allowing us to take photos or even become acquainted with
her. She was in need of psychiatric care but would not accept referral. Quite obvi-
ously to operate on this patient would be a grave error.
Rejection by multiple other plastic surgeons should always raise a red
ag.
THE DEPRESSED PATIENT
Patients who have not had an optimal result or even those who have had a satisfac-
tory outcome may occasionally experience postoperative depression.They may be
inclined to focus on small imperfections of a procedure or on the complication or
problem if one has occurred. It is important to recognize this condition early and
have the patient seek consultation if getting the patient to “open up and talk” does
not seem to help.
For hospitalized patients, the unfamiliar environment can also play a role in this
phenomenon. Often we are inclined to keep patients in the hospital to be able to
keep a close watch on “how the wounds heal.” However, a patient with a prolonged
hospitalization who has had complications naturally can become depressed. The
patient quickly grows weary of the hospital environment and, as the days wear on,
he is likely to feel that he is simply not getting any better, believe that no one cares,
and begin to dwell on the complication rather than looking forward to the future.
It is neither advisable nor desirable to keep a patient hospitalized until all wounds
are completely healed.There are two approaches to this situation.When the patient
has a wound that contains necrotic tissue, the patient can be returned to the oper-
ating room for debridement and coverage with either a skin graft or a local ap.
When the patient has a wound that is simply slow in healing, the patient can be dis-
charged and then monitored with close follow-up in the of ce. Many times visit-
ing nurse associations are a tremendous help in providing wound care or even par-
enteral therapy in the patient’s own home. This type of home management
certainly is not appropriate for every patient, and one does not want to give the im-
pression that the patient is being discharged prematurely. However, many patients
will view their impending discharge as a sign that they are getting better.The home
environment is often conducive to physical recovery and mental well-being.
The patient who has unrealistic expectations regarding the surgery may be at risk
for postoperative depression. Although plastic surgery is potentially life changing for
some patients, for the vast majority it is not.Those who expect that things will be

entirely different for them after cosmetic surgery set themselves up for profound
depression postoperatively once they realize that their world remains much the
same as before. Clearly the best way to avoid this outcome is prevention by careful
screening for appropriate motivation and by good preoperative counseling.
Another type of patient at risk for postoperative depression is the patient whose fa-
cial appearance has been dramatically changed. It is quite possible for an individual
to feel as if he or she has lost a familiar identity and in a sense feel like a com-
pletely different person.This phenomenon is not uncommon in patients who un-
dergo orthognathic surgery, rhinoplasty, and soft tissue contouring procedures. Post-
operatively, they actually might not be recognized by their own friends! A period
of readjustment must ensue during which depression can supervene despite a pro-
found improvement in appearance. Computer imaging can help patients develop
realistic expectations with a sense of how their appearance might change. These
issues should be addressed in the preoperative discussion.
THE PATIENT W ITH PAIN
Most people fear pain.The reoperative patient has already experienced some degree
of pain with the primary surgery and will naturally be concerned about how much
discomfort can be expected from the next operation. I have had several patients
forgo nipple-areola reconstruction following a TRAM ap breast reconstruction
because of the memory of the abdominal pain following the initial ap harvest and
mound construction. Despite my efforts to demonstrate that the breast mound is
insensate and that they will experience very little if any pain with nipple-areola
reconstruction, they cannot bring themselves to proceed with additional surgery.
They are willing to live without the completed reconstruction rather than submit
to a second elective operation no matter how “minor” the pain. In these situations,
the fear of pain becomes worse than the pain itself and is the dominant factor in in-
uencing whether a patient proceeds with elective reoperation.
Some patients develop unusual chronic pain syndromes subsequent to surgery. Not
always easily explained, these disorders can occur following procedures as diverse as
face lifts and lower extremity liposuction. Fortunately most patients improve with
time. One must be cautious about reoperating for pain alone. Often the result of
blind exploration is a patient who is no better and sometimes worse.The develop-
ment of neuromas because of previous incisions may often explain unresolved pain
syndromes (see Chapter 48). Diagnostic nerve blocks can be helpful in patients
who demonstrate point tenderness in known cutaneous nerve distributions.
The plastic surgeon would be well advised to rule out every other mechanical cause
of pain before referral. I prefer to refer patients with recalcitrant pain to a pain
clinic where various treatment modalities including group therapy are available.5
Massage and desensitization training by physical therapists may sometimes improve
localized chronic pain. If this fails, however, more sophisticated techniques of pain
control may be indicated. Medications such as gabapentin (Neurontin) or prega-
balin (Lyrica) may be of great bene t.The patient in whom pain develops with ob-
47
Chapter 2
The Patient

48
PART I
THE R EOPERATIVE ENVIRONMENT
vious secondary gain must also be identi ed, with careful documentation of the
objective signs and symptoms in the medical record.
THE PATIENT W HO HAS HAD MULTIPLE FAILED
OPERATIONS
Multiple failed procedures lead to anguish for both the patient and surgeon. Each
surgeon develops his or her own style for delivering good news and bad news and
for maintaining healthy doctor-patient relationships when things get rocky. By be-
ing exible and learning to read patients’moods and personalities, the surgeon can
adapt the approach depending on the circumstances.The key is to always maintain
healthy, open communication. It is important to let the patient know that the sur-
geon cares greatly about what has happened, and reassure the patient that they will
face the future together and that the surgeon can be trusted to provide guidance to-
ward the correct course of action.
All surgeons must recognize their own limitations.We are limited not only in what
we can do technically but also in our abilities to work with every type of patient.
At some point a surgeon may realize that he or she has reached the limit of what
can safely be accomplished for a patient or the limit of their ability to provide care.
It is then the surgeon’s obligation to refer the patient to another physician who
can assume care and responsibility.Those who exceed these limits doom both the
result and the doctor-patient relationship. When referring a dif cult patient, the
surgeon should call the new consultant personally, provide copies of all medical
records, and follow up to make certain the patient has been assisted in every way
possible to make the transition to a new treating physician a favorable one.
THE TERMINAL CANCER PATIENT
Occasionally a plastic surgeon will care for a terminal cancer patient who has had
complex reconstructions. It is well to remember that “it is better to give life to
years, not just years to life.”6 Preservation of dignity and hope in the nal months
of life is essential; the surgeon should do all possible to allow the patient to main-
tain a sense of esteem and worth.
Patients facing death will go through the well-known stages of adjustment, includ-
ing anger. It helps patients to have their physician face the anger with them and to
know that the physician will be with them to the end. Sometimes facing a bad sit-
uation squarely together can make the bleakest circumstance an experience that
both you and your patient will nd enriching.
MEDICOLEGAL CONSIDERATIONS
The very nature of reoperative plastic surgery increases the odds that a medical
malpractice claim may be led. Claims usually arise from a patient’s response to a
disappointing surgical result. Both the initial surgeon and the reoperating surgeon

are at high risk of liability stemming from various aspects of reoperative patient
care. Even though many types of reoperative surgery have no medical or legal re-
lationship to previous surgical care, the increased technical dif culty of reoperative
surgery and the unpredictability of the outcome make the reoperating surgeon a
target for malpractice. Patients need to be carefully counseled preoperatively, and
these discussions must be meticulously recorded in the medical record along with
photographs documenting preoperative appearance and postoperative result.
INFORMED CONSENT
All surgeons must be familiar with the elements of informed consent under their
own state law. The surgeon is required to provide the patient with a diagnosis, a
written and spoken description of the nature of the planned procedure including
its risks and bene ts, and an explanation of the consequence of not having the pro-
cedure.The process of obtaining informed consent under reoperative circumstances
is no different from that for obtaining it with primary surgery.There are very few
exceptions to the requirement for obtaining informed consent, particularly in plas-
tic surgery in which life-threatening emergencies that would preclude this discus-
sion are rare.7
ELEMENTS R EQUIRED FOR INFORMED CONSENT8
In general, ve types of information are required for informed consent.They are:
1. Diagnosis
2. Nature and purpose of the proposed procedure
3. Options for alternative treatments, including those which the treating plas-
tic surgeon may not perform
4. Risks, complications, and possible outcomes
5. Potential results if no treatment is performed
Actually, a detailed description of the procedure is not required although it is often
a good idea. Some patients request an explanation of the minute details of a pro-
cedure and others may not wish to know much of anything, saying,“Don’t tell me
what you are going to do, Doctor, just do it.” Although you might avoid address-
ing a step-by-step description of the procedure, you must spend time mentioning
commonly known risks and complications, for example, a hematoma following a
breast augmentation. Other consequences that might occur should be mentioned
but generally extremely unlikely risks do not require disclosure. It is always best to
err on the side of a more thorough discussion to avoid having to explain later in
court why a complication or unfavorable result was never mentioned.
A situation in which informed consent may not be required is when the surgeon
is aware that the patient has prior adequate knowledge. Also outcomes that are
commonly known do not always require discussion. Again, it is always safer to men-
tion risks, especially if they involve death, paralysis, or loss of other vital functions.
49
Chapter 2
The Patient

50
PART I
THE R EOPERATIVE ENVIRONMENT
When a patient who has had a complication or less than ideal result presents for an
initial consultation, it is common for the patient to begin pointing the nger at
the previous surgeon. He is likely to ask questions such as, “Why did things go
wrong?” or “Why didn’t Dr. X tell me something like this could happen?” It is im-
perative that the reoperative surgeon not indicate by facial expression or direct
comment even the slightest hint of dismay, disdain, or negative attitude toward the
patient’s surgical course or the previous surgeon. After all, you were not there, and
you probably do not have access to all of the medical records;even if you did, these
records would not necessarily re ect all of the factors that contributed to a partic-
ular medical or surgical decision. Instead, the surgeon should focus on the present
and the future. It is not for the reoperating surgeon to stand in judgment of the pa-
tient’s previous treatment or the patient’s previous surgeon.9
If you were the initial surgeon, then the informed consent process for the reoper-
ation is critically important. Extra time should be spent with the patient. Perhaps a
family member should be invited to be present. Patients are likely to judge all in-
formation that they are given for preoperative counseling for secondary surgery in
light of their own personal experience the rst time around.They may have linger-
ing misconceptions. Generally, the term minor surgery should be avoided. It should
be explained that reoperative surgery sometimes proceeds at a slower pace because
of previous scarring and alteration of anatomy. Bleeding can be more common.
Under some circumstances, the surgical plan must be altered based on intraopera-
tive ndings.These eventualities must be fully discussed with the patient.
The informed consent discussion should be documented in a handwritten note
recorded preoperatively in the patient’s chart. It is helpful to list all of the steps of
the planned procedure and all of the possible risks that were discussed. Sometimes
sketching an accompanying drawing in front of the patient clari es some of the
technical aspects of the planned procedure and helps the patient understand when
pitfalls may occur.
When the patient understands that the informed consent process is required by
law, he or she usually will not feel unduly frightened or concerned by the discus-
sion. The surgeon should use the experience to strengthen the doctor-patient re-
lationship. Elements from the patient’s previous surgery can be used to indicate
your concern for the patient’s safety and your thoroughness of preparation:“As we
discussed before your surgery, Mrs. Johnson, if the flap tissue appears to lose its
blood circulation, the best thing to do is to go right back to the operating room,
where we have a very good chance of being able to x it. That’s the reason we’ve
been checking on you so often since your surgery.” If you are not the original sur-
geon, you should make certain that you have inquired about various aspects of the
previous surgery.Was there increased bleeding? Did the patient have any dif culty
with general anesthesia? This information should then be incorporated in the in-
formed consent:“As you know, Mrs. Jones, your healing was delayed after your rst
operation.This could happen again because of the previous radiation therapy.”

51
Chapter 2
The Patient
If surgical residents are to be involved with the patient’s care, the patient needs to
understand the resident’s role in the surgical care team, training credentials, and
importance in helping to provide comprehensive surgical care.
MEDICAL R ECORD
The medical record is the physician’s written documentation of the nature and
progress of the patient’s treatment.10 We are obliged to maintain an adequate med-
ical record to assist in communication with other members of the medical commu-
nity, especially in a situation in which patients change physicians. The medical
record is also a written document of the informed-consent process. It should be
timely, precise, and legible. Every patient visit, from the initial consultation until -
nal discharge, including telephone calls and any other interactions, should be doc-
umented. It must be kept con dential and must neverbe altered.This is not to sug-
gest that errors, especially involving spelling and transcription, cannot be corrected,
but this must be done in the proper way. A mistake in the medical record is cor-
rected by drawing a simple line through it so that it can still be read, followed by the
corrected entry nearby and the date and initials of the editing party. Never try to
erase or obliterate an error, as this will almost always be an impossible act to defend
in court. Never be tempted to remove an old notation and substitute a new one in
the medical record, even if you really feel that an honest mistake was made. If ad-
ditional entries are to be made in the medical record, it is best to discuss them with
your attorney prior to making any changes.
The key in this process is to become a good communicator. Some patients learn
best by talking; others prefer looking at diagrams and drawings; and still others re-
quire a careful reading of a written document to incorporate the information be-
ing conveyed. For some patients a more personalized relationship to the plastic sur-
geon and staff is necessary to fully understand the information being presented. By
developing an open and caring bedside manner, all of the pertinent information can
be effectively communicated without unduly alarming even the reoperative pa-
tient. Above all, the surgeon should be approachable so that patients feel comfort-
able asking questions that they may even consider silly or unimportant.
CONCLUSION
The theory behind most reconstructive surgery is to take large chunks of muscle, skin, and bone
and slap them into the roughly appropriate place, then slowly carve this mess into some sort
of shape. It involves long operations, countless smaller ones, a lot of pain, and many, many
years. — Lucy Grealy, cancer patient11
This quote is how one patient summed up her lifelong experience with multiple
reoperations for a facial tumor. Although it might sound pessimistic, it helps us to
recognize that our patients might view the fruits of our labors somewhat differently
than we do! Fortunately, not all reoperative surgery is judged so harshly. However,

52
PART I
THE R EOPERATIVE ENVIRONMENT
our patients deserve to be honestly informed about what we recommend and the
chances for success or failure. They deserve to be intimately involved in the deci-
sion-making process. Many of the modes of dissatisfaction or adverse outcome of
reoperative plastic surgery result directly from poor patient preparation or com-
munication. All surgeons have patients who experience complications and failures.
However, totally separate from the actual aesthetic or reconstructive result of the
secondary surgery, the way we deal with our patients who require reoperation can
either maximize success or incite failure. Understanding the patient’s viewpoint
and where he ts into this complex dynamic will help to make the surgeon and the
patient partners in optimizing results.
References—With Key Annotated References
1. Anger GM.The seven deadly sins [book review]. New York Times, 1993.
2. Goldwyn R.The unfavorable result in reoperative plastic surgery. Presented at the Reoperative
Aesthetic Plastic Surgery Symposium, Amelia Island, FL, April, 1993.
3. Abrams M. Spotting psychiatric disorders in prospective patients. Aesthetic Plast Surg 17:9,
1993.
4. Sarwer DB. Body dysmorphic disorder. In Nahai F, ed. The Art of Aesthetic Surgery: Princi-
ples & Techniques. St Louis: Quality Medical Publishing, 2005.
5. Dobritt DW.The pain clinic: Its organization and application. Perspect Plast Surg 6:101-115,
1992.
6. Moyers BD. Healing and the Mind. New York: Doubleday, 1993.
This text explores the healing connection between the mind and the body from a host of angles, in-
cluding topics such as alternative medical treatments and the role of the mind in illness and recovery.
7. Sprung CL. Informed consent and the critically ill. Perspect Crit Care 1:61-72, 1988.
8. Reisman NR. Discussion of informed consent, record keeping, and documentation. In Gold-
wyn RM, Cohen MN, eds.The Unfavorable Result in Plastic Surgery: Avoidance and Treat-
ment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, pp 35-37.
A collection of more than 26 years of clinical research on the complications that can result from var-
ious cosmetic surgeries.The text highlights advances in plastic surgery, in areas like bone, skin, and
nerve grafts, facial reconstruction, and breast augmentation. Legal issues are also covered.
9. Lee JT, Cole PA. Medicolegal considerations. In Fry D, ed. Reoperative Surgery:Views of a
Surgeon and an Attorney in Reoperative Abdominal Surgery. Philadelphia: WB Saunders,
1986.
10. Sullivan WG. Informed consent, record keeping, and documentation. In Goldwyn RM, Co-
hen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed.
Philadelphia: Lippincott Williams & Wilkins, 2001, pp 29-35.
A collection of more than 26 years of clinical research on the complications that can result from var-
ious cosmetic surgeries.The text highlights advances in plastic surgery, in areas like bone, skin and nerve
grafts, facial reconstruction, and breast augmentation. Legal issues are also covered.
11. Grealy L. Mirrorings:To gaze upon my reconstructed face. Harper’s, Feb 1993, pp 66-75. Cited
in Yousif NJ, Larson DL. Evolution of the revolution in head and neck reconstruction. Perspect
Plast Surg 7:29-48, 1993.
Ms. Grealy presents a rst-person account of her lifelong struggle with cancer that appeared in her jaw
as a child. She recounts her chemotherapy as a young girl and a series of reconstructive procedures in
her adult years, and the surgery involving a tissue expander and a bone graft.

53
Chapter 2
The Patient
1. The most common reason cited by patients for changing physicians postoper-
atively is:
a. A perception that their plastic surgeon is uncaring or unavailable to ad-
dress their concerns
b. Financial issues
c. A perception that the physician’s staff is unfriendly and unhelpful
d. An inconvenient of ce visit schedule
e. A feeling that their plastic surgeon has a personality disorder
2. If reoperation is necessary, the well-prepared patient:
a. Will be disappointed but not shocked if reoperation is necessary
b. May feel “unfortunate”
c. Is able to remain optimistic about the future
d. Is aware that further treatment might produce better results
e. All of the above
3. Communicating with the reoperative patient is facilitated by:
a. “Stretching” the truth to make a complication understandable to the pa-
tient
b. Ignoring the deformity to concentrate on the positive
c. Attempting to minimize the problem to bolster the patient’s spirits
d. Dealing honestly with the patient to gain his or her trust
e. Not revealing the timetable for correction so as not to upset the patient
4. Body dysmorphic disorder is:
a. A condition in which a patient becomes preoccupied with and grossly
exaggerates a slight physical defect
b. An obsession with a gross physical deformity
c. Usually seen in children
d. Overdiagnosed in plastic surgery populations
e. Untreatable
5. The elements of informed consent include a discussion of:
a. Diagnosis
b. The nature and reason for the proposed treatment
c. Options for alternative treatments
d. Complications and risks
e. All of the above
R EVIEW QUESTIONS

(Trang không có chữ)

55
According to the American Society of Plastic Surgeons (ASPS), more than 10.2
million Americans underwent a cosmetic surgical or minimally invasive procedure
in 2005.1 The vast majority of procedures consisted of minimally invasive, nonsur-
gical procedures, which have increased by more than 50% since 2000.1 These num-
bers, although familiar to many plastic surgeons, are often staggering to other med-
ical professionals and lay persons who are unaware of the number of Americans
who turn to medicine to enhance their physical appearance.The dramatic increase
probably re ects an increased acceptance of and desire to improve appearance by
medical means, and underscores the premium that is placed on physical appear-
ance in contemporary society.2
Several factors have probably contributed to the growth in popularity of cosmetic
surgery.2-5 Changes in the medical and surgical communities, including improve-
ments in safety and the proliferation of direct-to-consumer marketing, have in-
creased access to cosmetic surgery.The role of physical appearance in daily social in-
teractions is another probable in uence. A large body of research suggests that more
attractive people are judged more favorably and receive preferential treatment in a
wide range of social situations.2,6 Widely watched “reality-based” television pro-
grams such as The Swan and Extreme Makeover have helped to champion cosmetic
surgery and further perpetuate the media’s historically unrealistic beauty ideals.
These in uential factors serve as a backdrop to the signi cant dissatisfaction that
many Americans experience with their physical appearance. Considering all of
Psychological Considerations in
Reoperative Plastic Surgery Patients
David B. Sarwer, Alexander W. Baker, and Alison L. In eld
C ha pter 3
Rollin Becker had a mantra he’d use before he saw a patient:
“Thank you for allowing me to watch you heal yourself.”
Hilmar Moore

56
PART I
THE R EOPERATIVE ENVIRONMENT
these factors, perhaps the dramatic increase in the popularity of cosmetic surgical
and minimally invasive treatments is not surprising.
Plastic surgeons and mental health professionals have been interested in the psycho-
logical aspects of cosmetic surgery for decades.7,8 Numerous studies have found
that patients report increased satisfaction with their appearance, as well as psycho-
logical improvements, postoperatively.7,8 Some patients, however, are less satis ed
with their postoperative appearance and ultimately undergo revision procedures
with the same or another surgeon. Precise statistics on the number of revision pro-
cedures performed each year are not available. However, 36% of patients who un-
derwent a cosmetic procedure in 2005 were considered to have undergone re-
peated procedures.1 Some of these were probably revision procedures.
Understanding the psychological characteristics of patients who desire and undergo
primary or secondary cosmetic procedures is important for at least two reasons.
First, cosmetic procedures are often seen as analogous to psychological interven-
tions;when successful, both result in psychosocial bene ts to the patient.3 Second,
there may be a subset of patients, particularly patients with certain psychiatric dis-
orders, for whom repeated or revision procedures may not be bene cial.
This chapter will provide an overview of the psychological aspects of cosmetic sur-
gery.The chapter begins with a review of studies that have investigated the psycho-
logical characteristics of individuals who have undergone the most common cos-
metic procedures. The chapter then provides an overview of body dysmorphic
disorder (BDD), the psychiatric disorder that may be most relevant to cosmetic
surgery patients in general, and speci cally to patients who seek repeated proce-
dures. The chapter concludes with a discussion of the psychological assessment of
patients who undergo cosmetic surgery.
PSYCHOLOGICAL ASPECTS OF THE MOST
COMMON COSMETIC PROCEDURES
R HINOPLASTY
Rhinoplasty is the second most popular cosmetic surgical procedure in the United
States, with just less than 300,000 performed in 2005.1 The psychological charac-
teristics of patients who undergo rhinoplasty have received as much research atten-
tion as the characteristics of people who have undergone any cosmetic procedure.7
The rst clinical reports date back to the 1940s and 1950s.9,10 Psychodynamic or
Freudian theory was the dominant theoretical orientation in psychiatry at the time
and in uenced interpretations of the preoperative motivations and postoperative
outcomes of patients.The initial reports, as well as subsequent investigations in the
1960s, suggested that patients were highly psychopathological.The nose was often
thought to symbolize the penis, and the desire for rhinoplasty was believed to rep-
resent the patient’s unconscious displacement of sexual con icts onto the nose.11,12
During the 1970s and 1980s, a “second generation” of research in cosmetic surgery
emerged and included valid and reliable psychometric measures to assess patients’

psychological characteristics.4,5,7,8 Studies conducted during this era found less pre-
operative psychopathology,13-16 and several studies reported postoperative improve-
ments in psychosocial status.14-18 Unfortunately, the validity of many of these stud-
ies has been called into question because of methodological problems such as small
sample sizes and the lack of appropriate control groups.7
More recent studies, several of which addressed previous methodological issues,
described less preoperative psychopathology and psychosocial improvement after
surgery.19-26 Unfortunately, despite a revision rate estimated at approximately 10%,27
formal investigations have yet to speci cally study the psychological characteristics
of patients who have undergone revision rhinoplasty. As discussed later in the chap-
ter, evidence suggests that some of these patients may suffer from BDD.
BREAST AUGMENTATION
Despite the long-standing debate about the safety and ef cacy of breast implants,
the number of women in the United States who have undergone breast augmen-
tation has risen by more than 700% in the last decade.1 A fairly extensive literature
has investigated the psychological characteristics of patients who have undergone
breast augmentation.8 Some studies have described the preoperative psychological
characteristics of these women; others have examined the psychological changes
that they experience postoperatively.
The stereotypical image of a patient who undergoes breast augmentation is a sin-
gle, European-American woman, in her early twenties, who is interested in breast
augmentation as a means of facilitating the development of a romantic relation-
ship. In reality, reports suggest that the average patient is in her late twenties or
early thirties, is married, and has children.8 Many of these women report that their
primary motivation for surgery is to return their breasts to their former, prechild-
birth shape and size. Nevertheless, women who range in age from their late teens
to mid-forties and who represent a variety of ethnic backgrounds present for breast
augmentation, making it probable that there is no “typical” patient.
Although it is dif cult to de ne the average breast augmentation patient, one can
identify some differences between women who have breast implants and those who
do not.Women who have undergone breast augmentation are more likely to have
more lifetime sexual partners, report a greater use of oral contraceptives, be younger
at their first pregnancy, and have a history of terminated pregnancies compared
with other women.28-31 They have also been found to use alcohol and tobacco
more frequently and to have higher rates of divorce.28-32 Many present for surgery
with a below-average body weight, leading to the concern that some may experi-
ence eating disorders.28-31,33-35
Several reports have described the preoperative body image concerns of patients
who undergo breast augmentation.33-38 These reports suggested that women inter-
ested in undergoing breast augmentation have greater dissatisfaction with their
breasts, greater investment in their overall appearance, and greater concern with
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their appearance in social situations compared with women who are not interested
in breast augmentation.33-36 In addition, candidates for breast augmentation were
more likely to practice signi cant behavioral avoidance in response to negative feel-
ings about their breasts compared with women who are not interested in surgery.36
Finally, prospective patients more frequently reported being the victims of teasing
about their physical appearance and of using psychotherapy than control patients.35
Studies of the more general psychological status of candidates for breast augmen-
tation have followed a similar pattern to studies of candidates for patients who un-
dergo rhinoplasty.39 Early reports relied on clinical interviews to assess preoperative
psychological functioning and found that patients experienced increased symptoms
of depression, anxiety, guilt, and low self-esteem.32,34,40-43 Subsequent studies have
been more likely to use valid and reliable psychometric measures, and typically
found fewer symptoms of psychopathology.37,38
Other studies have examined psychosocial changes postoperatively. Several have re-
ported improvements, or at least no change, in self-esteem and depressive symp-
toms. However, the most profound psychological effects of breast augmentation
may occur in the domain of body image. In one of the largest studies of psychoso-
cial outcomes in patients who have undergone breast augmentation, more than
90% of patients reported an improved body image 2 years postoperatively.44 Pa-
tient satisfaction and body image improvements, however, may be tempered by a
postoperative complication and revision surgery. Up to 25% of women experience
a surgical or implant-related complication, most commonly capsular contracture
or hardening of the breast.45-52 At least three studies have suggested that the expe-
rience of a complication is negatively related to postoperative satisfaction; women
who experienced postoperative complications reported less favorable improvements
in self-image and body image.44,45,53 During the last several years, ve large epi-
demiological studies in the United States and Europe designed to investigate the re-
lationship between breast implants and mortality found an unexpected relation-
ship between breast implants and suicide.54-58 The suicide rate (obtained from
patients’death records) was two to three times greater among patients with breast
implants compared with either patients who underwent other cosmetic surgical
procedures or population estimates.
The speci c nature of the relationship between breast implants and suicide is un-
known.Two hypotheses regarding this relationship, although speculative, have some
intuitive appeal. Some women may enter into surgery with unrealistic expectations
about the effect that breast augmentation will have on their lives.When these expec-
tations are not met, they may become despondent, depressed, and potentially suici-
dal. Alternatively, women who experience postoperative complications statistically
not associated with breast implants (for example, autoimmune and connective tissue
diseases), and who may require additional surgery, may believe these complications
are a consequence of their implants.These women may become depressed as a re-
sult of a lack of perceived or real attention from the medical community.

In their study, Jacobsen et al56 found an increased prevalence of preoperative hos-
pitalizations for psychiatric reasons in women with breast implants compared with
women who underwent other forms of cosmetic surgery or breast reduction.56
These results suggest that the increased suicide rate among women who have breast
implants may re ect some underlying psychopathology rather than a direct rela-
tionship to the implants.59,60 As noted previously, women seeking breast augmenta-
tion present for surgery with certain preoperative personality characteristics that
are associated with an increased risk of suicide. Joiner61 has argued that these and
other personality characteristics would actually predict an even higher suicide rate
than found in the epidemiologic investigations. He further suggested that postop-
erative improvements in body image may produce a protective effect from the oth-
erwise increased risk. Clearly, additional prospective epidemiologic and clinical
studies of the relationship between breast augmentation and suicide are needed.
LIPOSUCTION
More than 320,000 men and women underwent liposuction in 2005, making it
the most popular cosmetic surgical procedure.1 Few, if any, studies have speci cally
investigated the preoperative and postoperative psychological status of patients who
underwent liposuction. Clinical reports suggest that there is great deal of public
misperception about liposuction. Many patients mistakenly believe that liposuc-
tion leads to permanent changes in weight and body shape. Others believe that li-
posuction will result in “washboard abs” and perfectly smooth thighs. Unfortu-
nately, these “ideal” results may not occur in reality. Between 40% and 50% of
patients reported weight gain after surgery, and up to 29% claimed that their fat re-
turned to the surgical site.62,63 Most patients, however, report satisfaction with their
results and maintain a more proportional shape, even if they do gain weight post-
operatively.63
ABDOMINOPLASTY
Only one study64 has documented the psychosocial changes associated with ab-
dominoplasty. In this study, women reported signi cant improvements in overall
dissatisfaction with their body image and abdomen, and in self-conscious avoidance
of body exposure during sexual activity 8 weeks after surgery. Patients did not re-
port signi cant improvements in self-concept or general life satisfaction.These re-
sults are consistent with other postoperative studies that suggest that the impact of
cosmetic surgery procedures may be limited to speci c improvements of discontent
with body image, but not necessarily to more general psychosocial functioning.7,8
The number of men and women who seek abdominoplasty has increased by 115%
since 2000.1 This increase may be a result of the rising numbers of individuals with
extreme obesity who are now undergoing bariatric surgery (“stomach stapling”) to
achieve weight loss.65 Unfortunately, after the massive weight loss, many patients
who undergo bariatric surgery are left with excess folds of skin and fat on the ab-
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domen and other body areas.This redundant skin may contribute to increased dis-
satisfaction with body image,66 and as a result may lead patients to seek abdomino-
plasty and other body-contouring procedures. In 2005, more than 20,000 individ-
uals underwent extended abdominoplasty or a lower body lift after massive weight
loss; more than 30,000 women underwent breast reduction/ breast lifts.1 The high
complication rate associated with these body-contouring procedures often neces-
sitates subsequent surgical revision.67 Unfortunately, formal studies of the psycho-
logical characteristics of people who seek these body-contouring procedures have
yet to appear in the literature.
SURGICAL ANTIAGING PROCEDURES
In 2005, 108,955 rhytidectomy and 230,697 blepharoplasty procedures were
performed in the United States.1 Similar to the early studies of patients who under-
went rhinoplasty and breast augmentation, the rst studies of patients who under-
went facelift procedures suggested that these patients had considerable psycho-
pathologic characteristics. Patients were often characterized as dependent and
depressed; approximately 70% of patients received a preoperative psychiatric diag-
nosis.68,69 However, the majority of patients reported postoperative improvements in
well-being and did not experience postoperative emotional disturbances.68
More recently, the body image concerns of these and other patients undergoing
cosmetic surgery have become an area of great interest in the cosmetic surgery lit-
erature.3-5,7-8 In one of the rst empirical studies investigating the body image con-
cerns of patients who undergo cosmetic surgery, nearly half the patients studied
sought face-lift and/or blepharoplasty procedures.70 They reported higher levels of
dissatisfaction with the feature for which they sought surgery, but they did not re-
port increased dissatisfaction with their overall body image.70 Patients who under-
went rhytidectomy and/or blepharoplasty have reported greater investment in their
appearance as well as greater satisfaction with their overall body image compared
with women who sought rhinoplasty.26 Postoperatively, patients reported decreases
in dissatisfaction with their body image of the feature that was treated, but no
changes in overall body image.71
MINIMALLY INVASIVE ANTIAGING PROCEDURES
Minimally invasive antiaging procedures using products such as Botox and Resty-
lane have rapidly become the predominant form of cosmetic medical treatment in
the United States.1 These procedures have far surpassed the popularity of the more
traditional surgical procedures. Despite their popularity, little is known about the
psychological characteristics or body image concerns of the patients who seek these
procedures. A German study72 of 30 patients who received Botox injections for
improvement of facial lines examined posttreatment social outcomes and attitudes
toward appearance. More than half of the patients reported improvements in their
appearance and nearly 50% reported greater con dence in their appearance. A re-
cent study73 of 178 patients seeking laser skin resurfacing reported that 18% re-

ceived prior treatment for depression. A third study74 evaluated the psychosocial
bene ts associated with the use of alpha hydroxy acid. Patients noted signi cant
improvements in appearance and satisfaction with relationships after treatment.
Patients who undergo these procedures often return for subsequent treatments.
Repeated procedures are not technically “revision” procedures. However, they may
raise some concern about the possibility of signi cant body image dissatisfaction or
BDD, particularly in the absence of a noticeable physical “deformity.”
BODY DYSMORPHIC DISORDER
All of the major psychiatric diagnoses can probably be found within the population
of patients who undergo cosmetic and reconstructive surgery.4,5,7,8 However, there
is growing evidence that BDD may occur with greater frequency among popula-
tions of patients who undergo cosmetic surgery compared with the general popu-
lation.This disorder may appear with even greater frequency among patients who
present for revision procedures.
BDD is de ned as a preoccupation with an imagined defect in appearance (or if a
slight physical defect is present, the person’s concern is exaggerated) that results in
signi cant emotional distress or impairment in functioning for the patient.75 Al-
though not recognized as a formal psychiatric disorder in the United States until
1987,76 descriptions of people with the distinctive symptoms rst appeared in the
American dermatology and plastic surgery literatures much earlier. Reports in the
dermatology literature described patients presenting with a “dermatological nondis-
ease,”77 whereas reports in the plastic surgery literature described “minimal defor-
mity” and “insatiable” patients.78,79
BDD is estimated to occur in 0.5% to 2% of the general population,80,81 and rates
of 2.5% to 5% have been reported in university samples.82-85 In cosmetic surgery
and dermatology settings, however, the condition appears to be far more common.
Studies from several countries have suggested that between 7% and 15% of patients
who present to cosmetic surgeons or dermatologists suffer from the disorder.70,86-89
Thus it may be the psychiatric condition that warrants the most attention from
plastic surgeons.4,7,90
The onset of BDD typically occurs in late adolescence and is equally prevalent
among men and women.91,92 Although the most common sources of preoccupation
are the skin, hair, and nose, any body area may be the focus of concern.91-93 Preoc-
cupation with more than one feature is also common.93 Although the course of
BDD tends to be chronic, the features of concern, severity of symptoms, and degree
of insight into the disorder may vary over time.92,94
Patients often experience intrusive thoughts about their appearance or “defect.”
Although some may recognize the exaggerated nature of these concerns, others
may experience poor insight into their condition and hold delusional beliefs.95,96
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Skin picking, mirror checking, camou aging with cosmetics or clothing, and reas-
surance seeking are some ways patients with BDD attempt to decrease their dis-
tress.94,97-101 Others may engage in avoidance behaviors such as not looking in mir-
rors or refusing to leave the house. These behaviors may range in severity, but
typically involve 1 or more hours a day.98 The emotional distress and ritualistic be-
haviors often result in signi cant impairment in social and occupational function-
ing, and decreased quality of life.101-104 Self-harm and thoughts of suicide are rela-
tively common.92,94,100,103,104
Individuals with BDD frequently seek cosmetic and dermatologic treatments to cor-
rect their perceived defect and to lessen their concerns about appearance.92,93,103-105
In two large studies of BDD patients, more than 70% of patients sought and more
than 60% received such treatments.93,105 More than 90% of these treatments re-
sulted in either no change or a worsening in BDD symptoms. After treatment,
people with BDD often remain focused on the same body feature or become fo-
cused on a different feature. Studies suggest that nonpsychiatric treatments are of-
ten ineffective at reducing preoccupation with appearance, and in some cases may
even exacerbate symptoms.87,92,93 There are even some reports of dissatis ed pa-
tients displaying violence, and threatening or taking legal action against their sur-
geons.106-108 As a result, the presence of BDD is often considered a contraindication
for cosmetic procedures.* Psychopharmacologic and cognitive behavioral psy-
chotherapeutic interventions appear to be more effective strategies.112-124
PREOPERATIVE EVALUATION OF A PATIENT
UNDERGOING COSMETIC SURGERY
Within the past several years, greater attention has been paid to assessing the psy-
chological characteristics of patients who undergo cosmetic surgery.4,109,125,126 In
general, three areas should be assessed during the initial consultation: motivations
and expectations;body image dissatisfaction and BDD;and general psychiatric sta-
tus and history. In addition, surgeons (and their staff) should be observant of pa-
tients’behavior in the of ce. Finally, surgeons should be prepared to provide refer-
rals to mental health professionals when appropriate.
MOTIVATIONS AND EXPECTATIONS
Motivations for cosmetic surgery have been categorized as internal (for example,
undergoing the surgery to improve one’s appearance, body image, or self-esteem)
or external (for example, undergoing the surgery for some secondary gain such as
attempting to save a failing marriage).127-130 To assess the nature of the motivations,
it may be useful for the surgeon to start the initial consultation by asking why the
patient is interested in surgery at this time as opposed to undergoing such a proce-
dure 6 to 12 months ago.
*References 4, 5, 7, 90, 109-111.

Postoperative expectations have been categorized as surgical, psychological, and so-
cial in nature.129,131 Surgical expectations address the patient’s specific concerns
about the nature of the surgery (for example,“How much will it hurt?” or “How
long will I wear bandages?”) as well as the anticipated changes in postoperative ap-
pearance. In some cases, patients and surgeons may not agree on the postoperative
result. Patients may simply be dissatis ed with a technically satisfactory result or, in
more severe cases, they may be suffering from psychopathology that was not de-
tected preoperatively.These patients may be more likely to ask for revision proce-
dures, either from the original or a second surgeon. Additionally, these patients may
be likely to threaten or actually le lawsuits, and in the most extreme circumstances,
threaten violence or in ict physical harm on their surgeons.107
Psychological expectations include potential improvements in psychological func-
tioning such as anticipated changes in self-esteem after surgery. Social expectations
address the potential social bene ts of cosmetic surgery. Patients are typically judged
by others to be more physically attractive after surgery, but there is no evidence
that cosmetic surgery leads to changes in social or romantic behavior. Prospective
patients need to be reminded that an improvement in appearance is not likely to re-
sult in a change in the social responses of others. In their review of the literature on
the psychological aspects of cosmetic surgery, Honigman et al132 found three stud-
ies that suggested that unrealistic expectations are associated with lower levels of
postoperative satisfaction.40,44,133 In contrast, patients who are internally motivated
and who have realistic expectations are more likely to be satis ed with their post-
operative result.
DISSATISFACTION W ITH BODY IMAGE AND BODY
DYSMORPHIC DISORDER
Assessing the degree of preoperative dissatisfaction with body image is an essential
part of the preoperative consultation. Some dissatisfaction is typical with most pa-
tients and probably motivates the pursuit of surgery.* Body image also appears to
be the psychological construct most likely to change after cosmetic sur-
gery.44,64,71,85,135 Some patients, however, present for surgery with an intense and fre-
quent preoccupation with their comparatively “normal” appearance. As discussed
earlier, the report of extreme dissatisfaction, particularly in the presence of a min-
imal defect, may suggest the presence of BDD.
To assess for BDD, patients should be asked how their feelings about their appear-
ance impact their daily functioning. Patients may have BDD if they have no obvi-
ous defect in appearance and report that their concerns about appearance prevent
them from maintaining employment or relationships, or from engaging in daily ac-
tivities most people would perform without a second thought. It is important to re-
member, however, that the symptoms of BDD fall on a continuum. Severe cases in
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which individuals are unable to maintain employment or rarely leave their homes
can be relatively easy to recognize. In less severe forms of the disorder, individuals
are able to work and maintain relationships, but their quality of life suffers dramat-
ically. For example, they avoid various social situations or endure them with con-
siderable self-consciousness.These patients may be far more dif cult to identify.
Patients may unintentionally reveal the extent of their preoccupation with their
appearance in their initial consultation. Some may present the surgeon with numer-
ous photographs of models or celebrities who have the feature or features they de-
sire. Others may take photographs of themselves and, either through crude pencil
drawings or elaborate computer enhancements, attempt to depict the desired
changes. Still others may report a history of repeated cosmetic procedures or home-
made appearance remedies that they have tried.These behaviors should be consid-
ered as possible indicators of BDD.
The plastic surgeon may have a dif cult time identifying symptoms of BDD in pa-
tients who present for revision of an initial procedure or who report being dissat-
is ed with the results of a previous procedure from another surgeon. Although the
surgeon may believe that additional surgery can improve the “objective” appearance
of a feature, it is often the patient’s “subjective” perception of that feature that needs
additional treatment.The plastic surgeon faces a similar challenge when asked to re-
pair a self-in icted injury (for example, chronic skin picking), which may be symp-
tomatic of BDD.
Cosmetic surgeons are clearly aware of the presence of individuals with BDD in
their practices.107 When faced with a patient believed to have BDD, 84% of sur-
geons reported that they had refused to operate on a patient; 64% had scheduled a
second consultation; and 50% had referred the patient for a mental health consul-
tation. The vast majority (84%) of surgeons indicated that they had operated on a
patient who they believed was an appropriate candidate for surgery, only to realize
after the operation that the patient may have had BDD. Of surgeons who had this
experience, 82% reported that the patient had a poor outcome with regard to BDD
symptoms. Approximately 30% of survey respondents indicated that they had been
threatened legally by a patient who they believed had BDD, and approximately
10% reported that in addition to legal threats, they had been threatened physically.
This information, coupled with the nding that fewer than 10% of patients with
BDD report improvement in their symptoms after nonpsychiatric treatment, sug-
gests that BDD is a contraindication to cosmetic surgery.
GENERAL MENTAL HEALTH STATUS AND HISTORY
As in any medical consultation, the plastic surgeon should assess a new patient’s
mental health status and history. In addition to assessing the symptoms of BDD,
special attention should be paid to disorders with a body image component, such
as eating and mood disorders.

Eating Disorders
Given the central role of body image in both eating disorders and cosmetic surgery,
patients seeking procedures such as liposuction or breast augmentation should be as-
sessed for symptoms of anorexia nervosa and bulimia nervosa. To help assess for the
presence of these conditions, the height and weight of all patients should be used to
calculate body mass index (the patient’s weight [in kilograms] divided by their height
[in meters] squared).Patients with a BMI of less than 20 kg/m2 should be asked about
a history of recent weight uctuations,ongoing dieting efforts,binge eating,and purg-
ing or other compensatory behaviors.Women should be asked about amenorrhea.
Mood Disorders
Dissatisfaction with one’s body image also can contribute to a mood disorder.The
rst step in screening for a mood disorder is to identify irregularities in a patient’s
mood, affect, and overall presentation. If these symptoms suggest a potential mood
disorder, then neurovegetative symptoms, including sleep, appetite, and concentra-
tion should be assessed. If patients admit to having any of these symptoms, or if
their behavior suggests that they may have any of these symptoms, they should be
asked about the frequency of crying or irritability, social isolation, feelings of hope-
lessness, and the presence of suicidal thoughts.
An untreated mood disorder may contribute to the motivation for surgery because
patients may believe that they will feel better about themselves if they look better.
Underlying mood disorders also may contribute to lower levels of satisfaction with
the postoperative results. Many of these patients would probably be better served by
psychotherapeutic or psychopharmacologic treatment than by cosmetic surgery.
In addition to assessing current mental health status, the treating surgeon should ob-
tain a psychiatric history.This information should be routinely obtained as part of
a patient’s general medical history. If this information is typically collected before
the consultation, the patient’s responses should be reviewed during the initial visit.
Some patients are reluctant to candidly report their mental health histories, in part
out of fear that previous or ongoing treatment will preclude cosmetic surgery. Ap-
proximately 20% of patients who undergo cosmetic surgery report ongoing psychi-
atric treatment at the time of cosmetic surgery.136 Many of these patients probably
received these medications from their primary care physician and not from a psy-
chiatrist. Investigations from other surgical populations suggest that primary care
professionals often prescribe subtherapeutic dosages of these medications.137 Thus
the surgeon should not assume that a low dosage of an antidepressant medication
is appropriately controlling depressive symptoms.
Patients with a history of psychopathology who are not currently engaged in
mental health treatment may warrant a preoperative mental health consultation to
further assess their psychological status and appropriateness for surgery. Patients
currently in treatment should be asked if their mental health professional is aware
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of their interest in surgery. Surgeons should contact these professionals to con rm
that the proposed treatment is appropriate at this time. Patients who have not men-
tioned their interest in cosmetic surgery to their mental health provider, or who re-
fuse to allow the surgeon to contact that professional, should be viewed with cau-
tion. Such secretiveness was once commonplace; however, in today’s environment
of greater acceptance of cosmetic surgery, it may re ect a degree of paranoid think-
ing suggestive of psychopathology. Some patients who are dissatis ed with their
postoperative result have used their preoperative psychiatric history as part of their
legal action against the surgeon, arguing that their psychiatric condition prevented
them from fully understanding the procedure and its potential outcomes. These
occurrences underscore the importance of assessing and documenting the psychi-
atric status of all patients undergoing cosmetic surgery.
OBSERVING BEHAVIOR IN THE O FFICE
A 30- to 45-minute consultation is a relatively brief period of time to assess a pa-
tient’s psychosocial functioning. Patients typically are on their best behavior during
their initial consultation with a plastic surgeon and will often expend a great deal
of effort to present themselves as “appropriate” for surgery. Therefore every bit of
information obtained either during the consultation, or observed during interac-
tions with the nursing or of ce staff, should be used in making a determination of
appropriateness for surgery.
Nursing staff and of ce assistants are in unique positions to gather important infor-
mation about patients;they often witness different aspects of patients’behavior dur-
ing interactions outside of the surgeon’s eyesight. Patients who have dif culty fol-
lowing the office routine, as well as patients who frequently cancel or change
appointments, ask for appointments outside of of ce hours, or who do not wish to
talk to anyone other than the surgeon, should be reconsidered for surgery. These
behaviors often suggest the presence of psychopathology that may interfere with
the postoperative outcome. Patients who raise concerns among the staff should, at
a minimum, be seen for a second preoperative consultation. If concerns persist,
these patients should be referred to a psychologist or psychiatrist for a consultation.
MENTAL HEALTH R EFERRALS
A trusted psychologist or psychiatrist can be a valuable asset to a successful cos-
metic surgery practice. Given the relationship between body image dissatisfaction
and cosmetic surgery, a mental health professional with interest or expertise in body
image may be the ideal consultant.These professionals often work with other forms
of psychopathology that have a body image component, such as eating disorders or
BDD.They often are af liated with major medical centers or can be found in large
urban areas.
Patients may react to mental health referrals with anger, and some may even refuse
to accept the referral. These patients are probably not good candidates for treat-

ment. Unfortunately, in this current competitive environment, many patients will
“doctor shop” until they eventually nd a physician who will treat them, thereby
not receiving the mental health care they need. Hopefully, some patients will hear
the concerns of the surgeon they initially consulted and realize that cosmetic treat-
ment is not appropriate at this time. Therefore the surgeon must treat the referral
to the psychologist or psychiatrist like any other referral to a medical professional.
This practice often helps to destigmatize the mental health professional in the eyes
of the patient and makes the referral more acceptable. It is important to commu-
nicate to the patient the reason for the consultation. It may be useful to say:“Un-
dergoing a cosmetic medical treatment is an important decision.You are consider-
ing making changes to your appearance that are more or less permanent. These
treatments often lead to changes in how you feel about your appearance, some of
which may be positive, and others may be less positive. I think it is important that
we both are 100% sure that this treatment is right for you at this time.Therefore be-
cause I care about your well being, I would like you to see a psychologist (psychia-
trist) who often works with us to help us decide if this is the right time for surgery.”
Such a statement underscores the importance of the consultation to the patient in
a nonthreatening manner and hopefully prevents the patient from responding with
anger or hostility. Based either on the information gathered during the initial con-
sultation or after the patient has consulted a mental health professional, surgeons
may nd themselves in the unusual position of wanting to say “No” to patients
who have requested treatment. Training in both the medical and mental health
professions teaches professionals both directly and indirectly to help everyone who
seeks treatment. Nevertheless, there will be patients who ask for the wrong kind of
help. Some will ask for cosmetic surgery when a mental health treatment is more
appropriate. Others may ask for a treatment outside of the professional’s area of ex-
pertise. Still others may simply rub the professional the wrong way, making an ap-
propriate professional relationship dif cult. In these cases, the professional should re-
member that a cosmetic treatment is elective. Patients can elect to have them;
professionals can elect to say “no.”
If a medical professional decides to say “no” to a proposed treatment,
this should be communicated clearly, with sensitivity, and in person.
The conversation should be thoroughly documented in the chart and
followed by a letter to the patient.
Professionals who do not deal with these issues directly and who avoid these pa-
tients can put themselves at greater risk for legal action.
CONCLUSION
Over the last several decades there has been a great deal of interest in the psycho-
logical characteristics of people who seek cosmetic surgery, as well as their psycho-
logical responses postoperatively.These clinical reports and empirical studies can be
used to shape our understanding of the psychological considerations of a patient
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seeking revision procedures. These patients have received far less attention in the
scientific literature. Dissatisfaction with body image is believed to motivate the
patient to pursue cosmetic surgery and probably plays an equally important role in
revision procedures. Patients who present with excessive dissatisfaction after an ini-
tial procedure (performed by either the same or a different surgeon), as well as pa-
tients who acknowledge extreme dissatisfaction related to a minimal deformity,
may be suffering from BDD. These individuals are unlikely to bene t from addi-
tional surgery and may be more appropriately treated by a mental health profes-
sional. These patients also may be most likely to threaten or bring legal action
against the surgeon, or less frequently, to threaten or commit acts of violence against
the surgeon and the of ce staff. Appropriately assessing patients’ motivations and
expectations for surgery, their degree of dissatisfaction with body image, and their
current psychiatric status and history, may help identify patients for whom addi-
tional surgery is not appropriate.
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This chapter discusses the psychological assessment of cosmetic surgery patients from two different
perspectives. It begins by discussing the psychological evaluation of these individuals as conducted by
the plastic surgeon, with the goal of determining when a preoperative or postoperative referral to a men-
tal health professional is appropriate.The second half of the chapter discusses the psychological eval-
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129. Grossbart TA, Sarwer DB. Cosmetic surgery: Surgical tools—psychosocial goals. Semin Cu-
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132. Honigman R, Phillips KA, Castle DJ. A review of psychological outcomes for patients seek-
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