The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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(Trang không có chữ)

The Art of Aesthetic Surgery
Principles and Techniques
Third Edition
Editor
Foad Nahai, MD, FACS, FRCS (Hon)
Professor of Surgery
The Maurice J. Jurkiewicz Endowed Chair in Plastic Surgery
Department of Surgery
Emory University
Atlanta, Georgia, USA
Associate Editor
Farzad R. Nahai, MD
Board Certified Plastic Surgeon
The Center for Plastic Surgery at MetroDerm
Atlanta, Georgia, USA
Section Editors
John G. Hunter, MD, MMM, FACS
Chief, Division of Plastic Surgery
Associate Chief and Director of Clinical Operations,
Department of Surgery
New York-Presbyterian Brooklyn Methodist Hospital
Brooklyn, New York, USA
Attending Plastic Surgeon
New York-Presbyterian Hospital (Weill Cornell Campus)
Professor of Clinical Surgery (Plastic Surgery)
Weill Cornell Medical College
New York, New York, USA
William P. Adams Jr., MD
Program Director
University of Texas Southwestern Aesthetic Surgery Fellowship
Associate Professor
Dept. of Plastic Surgery
University of Texas Southwestern
University Park, Texas, USA
1653 illustrations
Thieme
New York • Stuttgart • Delhi • Rio de Janeiro
-H̵HU\ 0. .HQNHO 0'
Professor and Chair
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
W. Grant Stevens, MD, FACS
Clinical Professor of Plastic Surgery
University of Southern California Keck School of Medicine
Director
Aesthetic Surgery Fellowship
Marina del Rey, California, USA

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5 4 3 2 1

To Shahnaz
My best friend and partner of fifty years whose beauty is only surpassed by the loveliness that radiates from within.
Thank you for enriching my life.
—Foad Nahai, MD, FACS, FRCS (Hon)

(Trang không có chữ)

vii
Contents
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Video Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Volume I
Part I Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Section Editors: Foad Nahai and Farzad R. Nahai
1
The Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Foad Nahai
2
Psychological Considerations in Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
David B. Sarwer and Jacqueline C. Spitzer
3
Photographic Essentials in Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
:DOWHU & /LQ, :LOOLDP < +R̵PDQ, DQG )DU]DG 5 1DKDL
4
Patient Safety in Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Christopher A. Tokin, Christodoulos Kaoutzanis, Kent K. “Kye” Higdon, and James C. Grotting
5
Sedation and Anesthesia for Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Aaron M. Kearney, Sergey Y. Turin, and Sammy Sinno
Part II Business Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Section Editor: W. Grant Stevens
6
:hy Offer Aesthetic Medicine in an Aesthetic Surgical Practice" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Ali A. Qureshi, Renato Saltz, and W. Grant Stevens
7
Optimal Correction and Patient Retention: A Personal Philosophical and Practical Approach to Your
Nonsurgical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
A. Jay Burns
8
The Spa and the Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Michael S. Byrd
9
Social Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Anthony Youn
10
Hiring and Training a Superstar Patient-Care Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Karen A. Zupko
11
Evidence-Based Pricing Strategies That Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Karen A. Zupko
Part III Nonsurgical Cosmetic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
6HFWLRQ (GLWRU -H̵UH\ 0 .HQNHO
12
Clinical Decision Making for Nonsurgical Cosmetic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
0LNDHOD .LVOHYLW], )RDG 1DKDL, DQG -H̵UH\ 0 .HQNHO
13
Over-the-Counter Skin Care and Nutraceutical Basics for the Aesthetic Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Mary P. Lupo and Katharine Saussy
14
A Scientific Approach to Cosmeceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Leslie Baumann
15
Botulinum Toxin Injection for Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Sean Michael Devitt and Steven Fagien

viii
Contents
16
Soft-Tissue Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150
Vic A. Nanurkar
17
Non-Light-Based Skin Resurfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Christodoulos Kaoutzanis, Blair A. Wormer, and Galen Perdikis
18
Chemical Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Richard H. Bensimon and Foad Nahai
19
Lasers and Light-Based Devices in Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196
Noelani E. González and David J. Goldberg
20
Sclerotherapy and Laser Vein Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Gilly Munavalli, Mitchel P. Goldman, and Robert A. Weiss
21
Nonsurgical Treatment of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222
Michael P. Ogilvie and Julius W. Few Jr.
Part IV Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
6HFWLRQ (GLWRU -H̵UH\ 0 .HQNHO
22
Applied Anatomy in Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243
Alfonso Barrera
23
Clinical Decision Making in Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
Alfonso Barrera
24
Hair Transplantation: Follicular Unit Micrografting and Minigrafting—Current Techniques and Future Directions . . . . . 259
Alfonso Barrera
25
Reoperation, Refinement, and Treatment of Complications after Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . .270
Jack Fisher
Part V Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Section Editors: Foad Nahai and Farzad R. Nahai
26
Clinical Decision Making in Brow Lift: Brow Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283
Foad Nahai
27
Temporal Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291
Foad Nahai
28
Endoscopic Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .298
Foad Nahai
29
Endoscopic Brow Lift: My Personal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
H. Devon Graham III
30
Other Approaches to Brow Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .334
Foad Nahai
Part VI Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Section Editors: Foad Nahai and Farzad R. Nahai
31
Eyelid and Periorbital Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .343
Amy Patel and Guy G. Massry
32
Clinical Decision Making in Aesthetic Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357
Foad Nahai
33
Upper Eyelid Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Ted Wojno
34
Upper Blepharoplasty in the Asian Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389
H. Joon Kim
35
Ptosis Surgery in the Blepharoplasty Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .397
Ted Wojno

ix
Contents
36
Lower Eyelid Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
Mark A. Codner and Juan Diego Mejia
37
Transconjunctival Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425
Foad Nahai
38
The Lower Eyelid Pinch Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .439
/RUQH .LQJ 5RVHQfiHOG
39
Avoidance and Treatment of Complications of Aesthetic Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458
Ted Wojno


Volume II
Part VII Midface Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Section Editors: Foad Nahai and Farzad R. Nahai
40
Clinical Decision Making in the Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .473
Foad Nahai
41
Midface Recontouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .478
Patrick Tonnard, Alexis Verpaele, and Adriana Cely
42
Endoscopic Rejuvenation of the Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505
Renato Saltz, Gabriele Miotto, and Carlos Casagrande
Part VIII Surgical Rejuvenation of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Section Editors: Foad Nahai and Farzad R. Nahai
43
Clinical Anatomy of the Face and Neck: Visualizing the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Joel E. Pessa and Foad Nahai
44
Clinical Decision Making in Facelift and Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .529
Foad Nahai
45
Structural Fat Grafting: Basics and Clinical Applications in the Hand and Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Michael J. Cammarata and Sydney R. Coleman
46
The MACS Lift Short-Scar Rhytidectomy with Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .573
Patrick Tonnard, Alexis Verpaele, and Igor Pellegatta
47
Short-Scar Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .594
Daniel C. Baker
48
Extended SMAS Technique in Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .612
James M. Stuzin
49
Lamellar High-SMAS Facelift: Single-Flap Lifting of the Midface, Cheek, and Jawline . . . . . . . . . . . . . . . . . . . . . . . . . . . .634
Timothy Marten and Dino Elyassnia
50
Simultaneous Facelift and Facial Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687
Timothy Marten and Dino Elyassnia
51
Facial Implant Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .725
Imran Ratanshi and Michael J. Yaremchuk
52
Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .749
Foad Nahai
53
Secondary Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .771
Timothy Marten and Dino Elyassnia
54
Reoperative Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
James C. Grotting, Nirav B. Patel, and William J. Vinyard
55
Avoidance and Management of Complications in Facial Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .844
Foad Nahai

x
Contents
Part IX Rejuvenation of the Cheeks, Chin, Lips, and Ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
Section Editors: Foad Nahai and Farzad R. Nahai
56
Rejuvenation of the Aging Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .863
Christopher D. Knotts, Byron D. Poindexter, Robert K. Sigal, and George Weston
57
Refinements in Otoplasty Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .871
Kayvan Shokrollahi and Jamie Barnes
58
Rejuvenation of the Chin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .882
Stephen E. Metzinger, Salvatore Lettieri, and Aldo B. Guerra
Part X Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895
Section Editor: Farzad R. Nahai
59
Applied Anatomy of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .897
Rod J. Rohrich, Paul N. Afrooz, William P. Adams Jr., and Joel E. Pessa (Dedicated to the memory of Jack P. Gunter)
60
Clinical Decision Making in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .905
Farzad R. Nahai
61
Primary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913
Paul N. Afrooz and Rod J. Rohrich
62
Tip Grafting for Nasal Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .953
-H̵UH\ 7 6WHLW] DQG 'HDQ 0 7RULXPL
63
Asian Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .970
-H̵UH\ 7 6WHLW], 6KHHQD 6DPUD, DQG 'HDQ 0 7RULXPL
64
Ethnic Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .983
Ashkan Ghavami and Sean Y. Saadat
65
Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1002
-H̵UH\ 7 6WHLW], 5REHUW 7 &ULVWHO, DQG 'HDQ 0 7RULXPL
Volume III
Part XI Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Section Editor: William P. Adams Jr.
66
Applied Anatomy of the Breast. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1023
Kristin A. Boehm and Foad Nahai
67
The Process of Breast Augmentation: Optimizing Clinical Decisions and Outcomes in Breast Augmentation . . . . .1036
William P. Adams Jr. and Foad Nahai
68
Choosing the Right Breast Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1041
David A. Sieber
69
Breast Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1051
Patrick Mallucci
70
Fat Grafting of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1066
Emmanuel Delay and Andreea Carmen Meruta
71
Composite Primary and Revision Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1084
0LFKDHO 6FKHÁDQ, $GL 0DLVHO /RWDQ, DQG %UDGOH\ %HQJWVRQ
72
Capsular Contracture: Current Science, Prevention, and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1098
Nicholas Lahar, Jason Roostaeian, and William P. Adams Jr.
73
Primary and Revision Augmentation Mastopexy: Techniques and Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1106
Robert Cohen
74
Clinical Decision Making in Breast Reduction and Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1134
Foad Nahai

xi
Contents
75
Medial Pedicle Vertical Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1152
Elizabeth J. Hall-Findlay
76
Breast Reduction: The Lateral Pedicle Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1182
Moustapha Hamdi
77
Short-Scar Mammaplasty with a Pectoralis Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1195
Ruth Graf, Maria Cecília Closs Ono, and Thomas M. Biggs
78
Alternative Approaches to Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1209
(OL]DEHWK - +DOO)LQGOD\, 1LDPK &RUGX̵, *HQHYLHYH ) &DURQ, DQG 'RQ /DORQGH
79
Control and Precision in Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1235
James C. Grotting and Stephen M. Chen
80
Mastopexy and Breast Reduction in Massive-Weight-Loss Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1258
J. Peter Rubin and Jonathan Toy
81
Management of Breast Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1274
Glyn Jones
82
Treatment of Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1284
Alfredo Hoyos and David E. Guarin
Part XII Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
6HFWLRQ (GLWRU -H̵UH\ 0 .HQNHO
83
Applied Anatomy in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1293
Alfredo Hoyos and Mauricio Perez
84
Clinical Decision Making in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1316
0LNDHOD .LVOHYLW] DQG -H̵UH\ 0 .HQNHO
85
Noninvasive and Minimally Invasive Techniques for Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1327
Lawrence S. Bass, Jason N. Pozner, and Barry E. DiBernardo
86
Liposuction and High Definition Liposculpture: Basic Techniques and Safety Considerations . . . . . . . . . . . . . . . . . . .1341
Alfredo Hoyos and Mauricio Perez
87
Screening and Safety Issues in the Massive-Weight-Loss Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1361
Christopher K. Patronella, Stephanie Nemir, and Olivier A. Deigni
88
Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1372
Sepehr Egrari
89
Decision Making in Upper Back Contouring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1387
Joseph P. Hunstad and Alexandra C. Schmidt
90
Body Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1396
.DUHQ % /X DQG -H̵UH\ 0 .HQNHO
91
Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1409
Dennis C. Hammond and Jonathan Nathan
92
Gluteal Augmentation with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1444
Ashkan Ghavami and Vicky Kang
93
Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . .1461
-H̵UH\ 5 &ODLERUQH DQG 6LPHRQ :DOO -U
94
Aesthetic Abdominal Surgery in Men: BodyBanking with Autologous Fat Contouring and Silicone Six-Pack
Implant Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1474
Jordan D. Frey and Douglas S. Steinbrech
95
Male Massive-Weight-Loss Chest Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1483
2PDU ( %HLGDV DQG -H̵UH\ *XVHQR̵
96
Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1490
.DUDQ &KRSUD DQG -H̵UH\ 0 .HQNHO

xii
Contents
Part XIII Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1499
Section Editor: John G. Hunter
97
Applied Anatomy in Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1501
Franziska Huettner and John G. Hunter
98
Clinical Decision Making in Female Genital Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1506
John G. Hunter
99
Surgical and Nonsurgical Female Genital Rejuvenation: Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction: Part 1—Patient Selection and Preoperative
Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1509
Christine A. Hamori
100 Surgical and Nonsurgical Female Genital Rejuvenation: Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction: Part 2—Psychological Considerations and Patient
Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1518
Gemma Sharp
101
Surgical Alteration of the Labia Minora and Clitoral Hood: Part 1—Labia Minora Reduction Surgery Using
Edge Excision Techniques and Nonwedge Flap Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1523
Ryan E. Austin, Frank Lista, and Jamil Ahmad
102
Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2—Central Wedge Labiaplasty and Clitoral
Hood Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1536
Gary J. Alter
103
Surgical Alteration of the Labia Minora and Clitoral Hood: Part 3—Surgical Alteration of the Clitoral Hood . . . . . .1544
Carlo M. Oranges
104 Surgical Alteration of the Labia Majora and Mons Pubis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1550
John G. Hunter and Yhelda Felicio
105
Vaginal Rejuvenation and Perineoplasty, Surgical Alteration and Minimally Invasive Procedures: Part 1—
Vaginal Rejuvenation and Perineoplasty, Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1558
John R. Miklos and Robert D. Moore
106 Vaginal Rejuvenation and Perineoplasty, Surgical Alteration and Minimally Invasive Procedures: Part 2—
Vaginal Tightening, Surgical and Nonsurgical Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1572
Lina Triana
107
Labiaplasty and Hood Reduction Complication Avoidance and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1579
Michael P. Goodman
108 Female Genital Rejuvenation: Labia Minora Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1589
Michael P. Goodman
3DrW ;,9 Gender-Affirming Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1605
Section Editor: John G. Hunter
109 Clinical Decision Making for Gender-Affirming Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1607
Wilmina N. Landford, Paula M. Neira, and Devin O’Brien Coon
110
Gender-Affirming Surgery: Patient Selection and Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1615
Ara A. Salibian, Steven Lamm, and Rachel Bluebond-Langner
111
Gender-Affirming Surgery: Facial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1620
Ara A. Salibian and Rachel Bluebond-Langner
112
Gender-Affirming Surgery: Top Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1623
Tareq Ammari, Emily Sluiter, Katherine Gast, and William M. Kuzon Jr.
113
Gender-Affirming Surgery: Genital Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1637
David M. Whitehead and Loren S. Schechter

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-1

xiii
Preface
Preface
It has been almost twenty years since my good friend
and mentor John Bostwick, then chief of plastic surgery
at Emory, and Karen Berger, another good friend who,
at the time, was the CEO of Quality Medical Publishing,
encouraged me to undertake the task of editing a text-
book on aesthetic surgery. Their input and advice led to
the publication of the first edition of The Art of Aesthetic
Surgery in 2005. Six years later, in 2011, the second edition
was published. The first two editions were an immense
undertaking for me, but also rewarding and educational.
Both editions were written to address the enormous
demand for and interest in cosmetic surgery and the
need for comprehensive information on that topic. I had
not anticipated the warm reception both editions would
receive from colleagues throughout the world, and I have
been delighted, humbled, and gratified to witness its
continued popularity and enthusiastic readership. Recent
translations into Chinese, Korean, and Russian attest to the
ongoing global need for education in aesthetic surgery. I
never imagined, twenty years ago, that today I would be
writing the preface for a third edition.
:hy a third edition" Surely twice was enough for a project
of this magnitude. The answer is obvious: this is a dynamic
field continuing its rapid and significant growth, with
numerous, exciting new developments. Interest in this topic
has not abated over the years; in fact, it has grown stronger
and more vibrant. While many of the procedures touted
nine years ago are still being performed, others have been
replaced by new, less-invasive approaches or techniques that
emphasize volume replacement to enhance rejuvenation
procedures. Furthermore, new technology, noninvasive tech-
niques, and a number of new devices, fillers, and products
have enhanced our ability to provide our patients a broader
spectrum of options and improved outcomes. Clearly, after
nine years there was a need for a revision of the book to
reflect these dramatic and ongoing changes.
Today, nonsurgical cosmetic treatments, such as
injectables, continue to gain in popularity, whereas the
decline we had seen in some surgical approaches to facial
rejuvenation seems to be reversing. Nowhere is this change
more dramatic than in the area of brow rejuvenation.
Another important trend has been the emphasis on volume
enhancement in periorbital and facial rejuvenation, as well
as surgery of the breast. In keeping with these trends, we
have increased coverage of nonsurgical treatments and
injectables and have added new sections and chapters
dealing with volume and its role in facial rejuvenation and
the role of fat grafting in breast surgery.
In contrast to the reduction in the number of invasive
surgical procedures for facial rejuvenation being performed
today, there has been a dramatic increase in breast and
body-contouring procedures, in normal-weight patients,
and in individuals who have lost massive amounts of weight.
Accompanying this burgeoning interest and demand have
been advances, the development of new procedures,
and refinements of existing techniques. In keeping with
advances and demand for genital rejuvenation, we have
expanded that section and added a new section on gen-
der-affirming surgery.
I did not approach the task of this revision lightly. As
with the first two editions, it involved many late nights
and weekends spent writing and editing. A busy practice,
numerous academic and societal commitments, a journal
editorship, and an effort to bring more balance into my own
life were all forces working against such an undertaking.
Why, then, did I feel this was the right time to take on the
responsibilities and make the time commitment for editing
a third edition" Obviously, there was more than one reason.
My commitment to learning and teaching was a primary
motivator. From my earliest writings on muscle and mus-
culocutaneous flaps, to the editing of two editions of this
three-volume work on aesthetic surgery, I have always felt
an obligation to contribute to the literature and to help
advance our specialty. This book represents a continuation
of my lifelong dedication to this process. It has been a
wonderful way to reach out to young and experienced sur-
geons alike and to offer them insight into the remarkable
contributions made by leading experts worldwide. During
academic travels and interactions with plastic surgeons and
trainees all over the world, I have witnessed their interest
in aesthetic surgery and their desire to master the basics
of aesthetic surgery and learn about the latest techniques.
This new edition has been written to address that need and
to provide information on current advances that emphasize
safe and best practices to all aesthetic surgeons.
Recognizing my many commitments and the increasing
scope of the specialty led to the decision to invite others
to assist me; namely, my son, Farzad Nahai as coeditor and
section editor; Dr. -effrey .enkel and Dr. -ohn Hunter as
section editors, with each responsible for two sections; and
Dr. William Adams and Grant Stevens as section editors. I
felt this would not only lighten my load and speed up the
time to publication but would allow the coeditors to add
their expertise.
Every chapter has been revised with new material added.
Twenty new chapters, reflecting the growth and diversity
of our specialty, have been included. The amount of online
material has also grown, with nineteen operative videos,
fourteen of which are new, included in this edition. The
entire book is also available online for quick and portable
reference. It is with great pleasure that I welcome 105 new
contributors who, along with our previous contributors,
bring valuable insights and considerable expertise to this
new edition. The contributors, drawn from all parts of
the globe, represent several disciplines, including the four
core specialties. These contributors, all of whom have
distinguished themselves as educators and innovators,
have graciously succumbed to my gentle arm-twisting and
that of the section editors to provide us with outstanding
chapters on a diverse range of topics.

xiv
Preface
The positive feedback we have received on the clinical
decision-making chapters prompted the expansion of exist-
ing chapters and the inclusion of new ones. The additions
reflect the increase in the number of options now available
for each patient. These chapters reflect my own and the
section editors’ daily decision-making process, not only in
the operating room but also in the clinic, where we evaluate
new patients and care for them after the operation.
My personal interest and fascination with human
anatomy dates back to my first year in medical school. I
recall one of my teachers telling the class, “You will learn
anatomy three times and forget it three times.” He went on
to say that unlike other knowledge we would acquire over
the years, anatomy would never change. Of course, he was
right; anatomy does not change. However, it is important
to note that we change, and our understanding of anatomy
evolves and deepens with experience.
Back then, I never imagined that one day as a practicing
plastic surgeon not only would I remember all the anatomy
I learned, but I would also learn intricate details that were
unimaginable then. Little did I know that in some modest
way I would even contribute to that knowledge base. Interest
in anatomic detail as it applies to aesthetic surgery continues
with further clarification of facial anatomy, such as the fat
compartments and more detailed descriptions of anatomy of
the trunk and breast relating to emerging body-contouring
procedures. In keeping with these new findings, all anatomy
chapters have been appropriately updated.
The topic of patient safety also assumes a more promi-
nent position in this edition, with a major chapter on safety
considerations in aesthetic surgery, as well as specific chap-
ters on problems and complications in different anatomic
regions.
All volumes have been significantly updated with new
information³each chapter reflects the latest information
presented by experts responsible for advancing our knowl-
edge in those areas.
As the book progressed from first to third edition, the
cover also changed. The first edition cover with a modern
rendition of The Three Graces was replaced with an even
more contemporary rendition of The Three Graces. The third
edition carries the masters version of The Three Graces.
It is my wish that readers will receive this third edition
with enthusiasm equal to that of the first two editions. I
hope that it will provide a source of new information, stim-
ulate thought, and foster innovation. As with any writing
project, this book has been a major undertaking, but it has
also been a labor of love. I have learned as much as I have
taught, and I continue to marvel at the outstanding work
being done by my colleagues around the world. I am grat-
ified to be able to share our learning and work with you in
these pages. My goal for this book is to provide trainees, as
well as experienced practitioners, with a solid foundation
for learning basic principles and techniques in aesthetic
surgery in order to enable them to build on it and advance
this specialty that we all love.
Foad Nahai, MD, FACS, FRCS (Hon)

xv
Acknowledgments
Acknowledgments
This book is intended to serve as a testament to all the
surgical pioneers who laid the foundation for modern aes-
thetic surgery, as well as a tribute to current contributors
worldwide whose ingenuity and skill are paving the way for
future developments. While acknowledging my mentors,
I also credit the young surgeons in whose training I have
been privileged to participate. Their enthusiasm and quest
for knowledge continues to stimulate me.
This work would never have been completed with-
out the support and encouragement of my family, my
partners, those with whom I work on a daily basis at
the Emory Aesthetic Center, and my friends at Thieme
Publishers. I would be remiss if I didn’t mention all of
them by name.
My wife, Shahnaz, has been a support and a part of my
professional life for fifty years. She, more than anyone,
has put up with my unusual hours and weekends away
from home. My son, Farzad, now associate editor of
this work, and my daughter, Fariba, have always been
interested in what I do and have encouraged me in my
efforts. My partners at the Emory Aesthetic Center Grant
Carson—Bert Losken, Monte Eaves, Gabi Miotto, and
Vince Zubowicz—provided encouragement, advice, and
most of all, support in looking after my patients while I
was working on the book. Trina Walker, my patient care
coordinator, has been my right hand for her hard work
and support.
Farzad Nahai, in addition to his role as section editor,
worked diligently, capably assisting me with all aspects of
putting this work together. The section editors—W. Grant
Stevens, -effrey M. .enkel, :illiam P. Adams, and -ohn G.
Hunter—all lightened my load and assured that this publi-
cation would be the best possible.
I am indebted to all at Thieme, notably my friend and
adviser Sue Hodgson, who demonstrated her profession-
alism and talent as an editor in her willingness to work
and rework with me until we both felt we had a superb,
scholarly, and “aesthetically” appealing product. Judith
Tomat not only encouraged but also managed to corral all
the contributors and section editors (and the editor as well)
into submitting their manuscripts and videos in a some-
what timely manner. Sarah Landis provided the follow-up
to process content for publication, gathering missing ele-
ments and keeping all aspects of the book in order and on
target. Illustrators Brenda L. Bunch, Amanda Behr, Graeme
Chambers, Amanda Tomasikiewicz, and Bill Winn provided
quality images to accompany the text.
I acknowledge the outstanding contributors to the book,
not only the original contributors who updated and in
some cases totally rewrote their chapters, but also the new
authors whose contributions have filled in any deficiencies
that may have existed in the second edition. I am most
grateful to them for so generously and readily sharing their
expertise with us.
Foad Nahai, MD, FACS, FRCS (Hon)
It is an honor for me to be included in the third edition of
The Art of Aesthetic Surgery, for so long referred to by me
as “dad’s book.” When my father approached me to assist
with the organization, writing, and editing of this book, I
was thrilled—thrilled for the opportunity to contribute to
the project in a meaningful way, but especially to have the
chance to share this experience with him, working closely
together to learn the ins and out of putting together a book
like this one. It has been a joy for us to collaborate, so I am
most grateful to my father for inviting me to be a part of
this project and for his continued guidance, mentorship,
patience, and leadership. As special as it is for him to share
a passion for plastic surgery with me and work together on
the common goal of publishing this third edition, it is an
equally special experience for me.
The support of my wife Dana and my children Marcelle
and Andre has also been important. I especially appreciate
their understanding when I have needed to leave the house
in the morning before they are awake to work on the book
before my clinical day starts.
I would like to also recognize my mentors and their
influence on me as a surgeon. The influence of my
dad on my career as a surgeon is immense and goes
beyond the scope of this note to fully recount and detail.
Stephen Mathes, whom I’ve been fortunate to know
since I was a kid, was my chief during residency. He
taught me the value of hard work and commitment to
the patient. He was taken from us too soon, but I feel
so fortunate to have had the time with him that I did.
Bill Hoffman (who coauthored the photography chapter
with me) was a big influence on me during my time as
a resident. To this day I recall and still abide by many
of his wise practices and anecdotes. David Young, Keith
Denkler, Lorne Rosenfield, and Gil Gradinger were also
major influences during my training and remain dear to
me to this day.
I must make a special mention with regard to Ron
Gruber. Ron was kind enough to allow residents who were
interested in rhinoplasty to spend time with him in his
private practice. I went to his office quite often, and Ron
was always very welcoming and eager to teach me about
rhinoplasty. Much of what I know about rhinoplasty
and the success of my rhinoplasty practice I owe to Ron.
Much of my chapter on rhinoplasty and my approach to

xvi
Acknowledgments
rhinoplasty is based on his mentorship and the approach
he taught me. Without Ron’s gracious time and teaching,
I would probably not be the rhinoplasty surgeon I am
today.
I would also like to mention my staff and partners at The
Center for Plastic Surgery at MetroDerm, who supported
me in my clinical practice to where I could take the time
needed to work on this book.
Lastly, none of this would be possible without the
excellent team at Thieme, especially Judith Tomat and Sue
Hodgson, who both put in a lot of time and hard work to
help make this third edition become a reality.
Farzad R. Nahai, MD
Thank you to Suzanne, Matthew, and Ashley for the many
sacrifices you have made to allow me to pursue my profes-
sional dreams. Your boundless support continues to be the
backbone of my successes.
Thank you to the students, residents, and fellows who
have allowed me the privilege of teaching. You have driven
me to pursue excellence and allowed me to be a small part
of your accomplishments.
To my patients, I am indebted to each of you for allowing
me to care for you. It has been my pleasure and honor to
do so.
-H̵UH\ 0 .HQNHO, 0'
I thank Foad 1ahai, MD, for conceiving of and first pub-
lishing in 2005 this internationally and critically regarded
masterpiece in aesthetic plastic surgery. The impact of the
initial text on the aesthetic surgery community, as well
as its second edition in 2011, cannot be overstated. I am
honored and humbled to be included by Dr. Nahai as a
coeditor for this Third Edition, entrusted with the devel-
opment of two new sections: female genital rejuvenation
surgery and gender affirming surgery. Both additions
reflect remarkable changes in aesthetic surgery that have
occurred since publication of the second edition and illus-
trate just how state-of-the-art The Art of Aesthetic Surgery
has been and continues to be.
I also thank my chapter coauthors and all the authors
who generously contributed chapters to both sections that
I edited. I also offer very special thanks to Ms. -udith Tomat
of Thieme Medical Publishers for her constant assistance,
support, and positivity throughout the editorial process.
John G. Hunter, MD, MMM, FACS
I would like to acknowledge Dr. Foad Nahai and all of the
section editors for their tireless work in completing this
edition of The Art of Aesthetic Surgery. I would also like to
thank all of the authors who contributed to this landmark
aesthetic surgery and medicine textbook.
W. Grant Stevens, MD, FACS
I acknowledge all surgeons who rise above the noise and
seek to truly move the needle with advancement of the art
and science of breast surgery.
William P. Adams Jr., MD

xvii
Contributors
Contributors
William P. Adams Jr., MD
Program Director
University of Texas Southwestern Aesthetic Surgery
Fellowship
Associate Professor
Dept. of Plastic Surgery
University of Texas Southwestern
University Park, Texas
3DXO 1. $IURR] 0'
Plastic Surgery
Private Practice
Miami, Florida, USA
Jamil Ahmad, MD, FRCSC
Director of Research and Education
The Plastic Surgery Clinic
Mississauga, Ontario, Canada
*DU\ -. $OWHU 0'
Assistant Clinical Professor of Plastic Surgery
University of California School of Medicine
Los Angeles, California, USA
Tareq Ammari, MBBS, BSc (Hons), MRCSed
Specialty Doctor in Plastic Surgery
Department of Plastic Surgery
National Health Service
United Kingdom
Ann Arbor, Michigan, USA
5\DQ E. $XVWLQ 0' )5C6C
Plastic Surgeon
The Plastic Surgery Clinic
Mississauga, Ontario, Canada
'DQLHO C. %DNHU 0'
New York, New York, USA
Jamie Barnes, MBChB, MRes, MRCS, FRCS (Plast)
Specialty Registrar in Burns and Plastic Surgery
Whiston Hospital
Liverpool, United Kingdom
$OIRQVR %DUUHUD 0' )$C6
Clinical Assistant Professor
Department of Plastic Surgery
Baylor College of Medicine
Houston, Texas, USA
/DZUHQFH 6. %DVV 0' )$C6
Clinical Assistant Professor
Department of Plastic Surgery
Zucker School of Medicine at Hofstra/Northwell
New York, New York, USA
Leslie Baumann, MD
CEO Skin Type Solutions
Miami, Florida, USA
Omar E. Beidas, MD
Plastic Surgeon
Orlando Health Aesthetic and Reconstructive Surgery Institute
Orlando, Florida, USA
%UDGOH\ %HQJWVRQ 0' )$C6
Founder and CEO
Bengtson Center for Aesthetics and Plastic Surgery
Co-Founder, Plastic Surgery Imaging, LLC
Grand Rapids, Michigan, USA
Richard H. Bensimon, MD
Private Practice
Portland, Oregon, USA
7KRPDV 0. %LJJV 0'
Clinical Professor of Plastic Surgery
Baylor College of Medicine
ICON, American Association of Plastic Surgeons
Houston, Texas, USA
5DFKHO %OXHERQG/DQJQHU 0'
Laura and Isaac Perlmutter Associate Professor of Plastic
Surgery
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Health
New York, New York, USA
.ULVWLQ $. %RHKP 0' )$C6
Plastic Surgeon
Private Practice
Premier Image Cosmetic and Laser Surgery
Atlanta, Georgia, USA
$. -D\ %XUQV 0' )$C6
Medical Director
EpiCenter Skin Care and Laser Center
Dallas Medical Skin Solutions
Dallas, Texas, USA
0LFKDHO 6. %\UG EVT.
Byrd Adatto, PLLC
Dallas, Texas, USA
Michael J. Cammarata, BS
University of California–San Francisco
San Francisco, California, USA
Genevieve F. Caron, MD, FRCSC
Plastic Surgeon
Department of Plastic Surgery
CIUSS Est-de-l’Ile-de-Montreal
Montreal, Quebec, Canada

xviii
Contributors
CDUORV CDVDJUDQGH 0'
Director, Plastic Surgeon
Casagrande Clinic
Florianópolis, Brazil
$GULDQD CHO\ 0'
Plastic Surgeon
Department of Aesthetic Plastic Surgery
The Carolina Clinic
Bogotá DC, Colombia
Stephen M. Chen, MD
Private Practice
Richmond Plastic Surgeons
Richmond, Virginia, USA
.DUDQ CKRSUD 0'
Plastic Surgeon
Twin Cities Cosmetic Surgery
Minneapolis, Minnesota, USA
-H̵UH\ 5. CODLERUQH 0'
Private Practice
Plastic Surgeon
Northshore Plastic Surgery
Mandeville, Louisiana, USA
0DUN $. CRGQHU 0' )$C6
Clinical Assistant Professor of Plastic Surgery
Department of Surgery
Emory University
Atlanta, Georgia, USA
Robert Cohen, MD, FACS
Medical Director
Scottsdale Center for Plastic Surgery
Paradise Valley, Arizona, USA
6\GQH\ 5. CROHPDQ 0'
Clinical Assistant Professor
Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, USA
Devin O’Brien Coon, MD, MSE
Assistant Professor of Plastic Surgery and Biomedical
Engineering
Johns Hopkins University
Baltimore, Maryland, USA
1LDPK CRUGX̵ 0% %6 )5$C6
Specialist Plastic Surgeon
Geelong, Victoria, Australia
Robert T. Cristel, MD
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
University of Illinois–Chicago
Chicago, Illinois, USA
2OLYLHU $. 'HLJQL 0' 03+
Plastic Surgeon
Private Practice
Deigni Plastic Surgery
Houston, Texas, USA
EPPDQXHO 'HOD\ 0' 3K'
Plastic Surgeon
Lyon, France
Sean Michael Devitt, MD
Plastic and Reconstructive Surgeon
University of Texas Southwestern
Dallas, Texas, USA
%DUU\ E. 'L%HUQDUGR 0'
Plastic Surgeon
Medical Director
New Jersey Plastic Surgery
Montclair, New Jersey, USA
6HSHKU EJUDUL 0' )$C6
Medical Director
Egrari Plastic Surgery Center
Bellevue, Washington, USA
'LQR EO\DVVQLD 0' )$C6
Marten Clinic of Plastic Surgery
San Francisco, California, USA
6WHYHQ )DJLHQ 0' )$C6
Private Practice
Cosmetic Oculoplastic Surgery
Boca Raton, Florida, USA
Yhelda Felicio, MD
Department of Plastic Surgery
Health Secretary of the Ceará State of Brasil
Plastic Surgery Service
Fortaleza, Ceará, Brazil
-XOLXV :. )HZ -U. 0'
Director
The Few Institute for Aesthetic Plastic Surgery
Clinical Professor
University of Chicago Pritzker School of Medicine
Plastic Surgery
Chicago, Illinois, USA
-DFN )LVKHU 0'
Associate Clinical Professor
Department of Plastic Surgery
Vanderbilt University
Nashville, Tennessee, USA
-RUGDQ '. )UH\ 0'
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Health
New York, New York, USA

xix
Contributors
.DWKHULQH *DVW 0' 06
Assistant Professor of Surgery
Division of Plastic Surgery
University of Wisconsin
Madison, Wisconsin, USA
$VKNDQ *KDYDPL 0'
Assistant Clinical Professor
David Geffen UCLA School of Medicine
Division of Plastic Surgery
Los Angeles, California, USA
Private Practice
Ghavami Plastic Surgery, LLC
Beverly Hills, California, USA
'DYLG -. *ROGEHUJ 0' -'
Skin Laser and Surgery Specialists of New York/New Jersey
Clinical Professor of Dermatology
Past Director of Mohs Surgery and Laser Research
Icahn School of Medicine at Mount Sinai
Clinical Professor of Dermatology
Chief, Dermatologic Surgery
UMDNJ–Rutgers Medical School
Adjunct Professor of Law
Fordham Law School
New York, New York, USA
Mitchel P. Goldman, MD
Volunteer Clinical Professor of Dermatology
University of California–San Diego
Medical Director, West Dermatology
San Diego, California, USA
Noelani E. González, MD
Instructor, Dermatology
The Mount Sinai Hospital
New York, New York, USA
Michael P. Goodman, MD
Medical Director
Caring for Women Wellness Center
Davis, California, USA
5XWK *UDI 0' 3K'
Professor
Department of Plastic Surgery
Universidade Federal do Paraná
Curitiba, Paraná, Brazil
H. Devon Graham III, MD
Department of Otolaryngology–Head and Neck Surgery
Division of Facial Plastic and Reconstructive Surgery
Ochsner Medical Center
New Orleans, Louisiana, USA
-DPHV C. *URWWLQJ 0'
Clinical Professor
Division of Plastic Surgery
University of Alabama–Birmingham
Private Practice
Grotting Plastic Surgery
Birmingham, Alabama, USA
David E. Guarin, MD
Plastic Surgeon
Department of Plastic Surgery
Plastic UV Research Team
Universidad Del Valle
Cali-Valle del Cauca, Colombia
Aldo B. Guerra, MD, FACS
Guerra Plastic Surgery Center
Scottsdale, Arizona, USA
-DFN 3. *XQWHU 0' GHFHDVHG
Founder of the Gunter Center for Aesthetics and Cosmetic
Surgery
Founder of the Dallas Rhinoplasty Symposium
Dallas, Texas, USA
-H̵UH\ *XVHQR̵ 0'
Professor of Plastic Surgery
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania, USA
EOL]DEHWK -. +DOO)LQGOD\ 0' )5C6C
Private Practice
Banff Plastic Surgery
Banff, Alberta, Canada
Moustapha Hamdi, MD, PhD
Professor and Head of Plastic Surgery Department.
Brussels University Hospital
Vrij Universiteit Brussel
Brussels, Belgium
Dennis C. Hammond, MD
Partners in Plastic Surgery
Associate Program Director
Spectrum Health Integrated Plastic Surgery Residency
Grand Rapids, Michigan, USA
Christine A. Hamori MD
Director of the Cosmetic Surgery and Skin Spa
Duxbury, Massachusetts, USA
.HQW .. ´.\Hµ +LJGRQ 0' )$C6
Associate Professor
Program Director
Department of Plastic Surgery
Vanderbilt University Medical Center
Nashville, Tennessee, USA
:LOOLDP <. +R̵PDQ 0'
Stephen J. Mathes Endowed Chair
Professor and Chief
Division of Plastic and Reconstructive Surgery
University of California–San Francisco
San Francisco, California, USA
$OIUHGR +R\RV 0'
Plastic Surgeon
Total Definer Medical
Bogota, Colombia

xx
Contributors
)UDQ]LVND +XHWWQHU 0' 3K' )$C6
Plastic Surgeon
Lenox Hill Hospital Northwell Health
Manhattan Plastic Surgery
New York, New York, USA
Joseph P. Hunstad, MD, FACS
Associate Clinical Professor
Plastic Surgery Division
University of North Carolina–Chapel Hill
North Carolina
Director, the American Society for Aesthetic Plastic Surgery
President, HKB Cosmetic Surgery Center
Huntersville, North Carolina, USA
John G. Hunter, MD, MMM, FACS
Chief, Division of Plastic Surgery
Associate Chief and Director of Clinical Operations,
Department of Surgery
New York-Presbyterian Brooklyn Methodist Hospital
Brooklyn, New York, USA
Attending Plastic Surgeon
New York-Presbyterian Hospital (Weill Cornell Campus)
Professor of Clinical Surgery (Plastic Surgery)
Weill Cornell Medical College
New York, New York
*O\Q -RQHV 0' )$C6
Illinois Cosmetic and Plastic Surgery
Professor of Surgery (Plastic a Reconstructive)
University of Illinois College of Medicine at Peoria
Peoria, Illinois, USA
9LFN\ .DQJ 0'
Associate Medical Director
Myovant Sciences
Los Angeles, California, USA
CKULVWRGRXORV .DRXW]DQLV 0'
Assistant Professor, Plastic and Reconstructive Surgery
Department of Surgery
University of Colorado, Anschutz Medical Campus
Aurora, Colorado, USA
$DURQ 0. .HDUQH\ 0'
Division of Plastic Surgery
Northwestern University
Chicago, Illinois, USA
-H̵UH\ 0. .HQNHO 0'
Professor and Chair
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
+. -RRQ .LP 0'
Assistant Professor
Department of Ophthalmology
Emory Eye Center
Atlanta, Georgia, USA
0LNDHOD .LVOHYLW] %61 51
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
CKULVWRSKHU '. .QRWWV 0' )$C6
Plastic Surgeon
The Austin-Weston Center for Cosmetic Surgery
Reston, Virginia, USA
:LOOLDP 0. .X]RQ -U. 0' 3K'
Reed O. Dingman Collegiate Professor of Surgery
Section of Plastic Surgery
University of Michigan
Ann Arbor, Michigan, USA
Nicholas Lahar, MD
Plastic and Reconstructive Surgery
Lahar Plastic Surgery
Beverly Hills, California, USA
Don Lalonde, MD, FRCSC
Professor, Surgery
Dalhousie University
Division of Plastic Surgery
Saint John, Canada
Steven Lamm, MD
Clinical Professor of Medicine
Director of the Preston Robert Center for Men’s Health
Department of Medicine
New York University
New York, New York, USA
:LOPLQD 1. /DQGIRUG 0'
Plastic and Reconstructive Surgery
Johns Hopkins Hospital
Baltimore, Maryland, USA
Salvatore Lettieri, MD, FACS
Assistant Professor
Division of Plastic Surgery
Mayo Clinic
Phoenix, Arizona, USA
Walter C. Lin, MD
Attending Surgeon
The Buncke Clinic
San Francisco, California, USA
)UDQN /LVWD 0' )5C6C
Founder, Medical Director
The Plastic Surgery Clinic
Trillium Health Parnters
Assistant Professor
Division of Plastic and Reconstructive Surgery
University of Toronto
Toronto, Ontario, Canada

xxi
Contributors
Adi Maisel Lotan, MD
Department of Plastic and Reconstructive Surgery
Shaare Zedek Medical Center
Jerusalem, Israel
.DUHQ %. /X 0'
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
0DU\ 3. /XSR 0' )$$'
Clinical Professor of Dermatology
Tulane Medical School
New Orleans, Louisiana, USA
3DWULFN 0DOOXFFL 0' 0%CK% )5C'6 3ODVW
Malucci London
London, United Kingdom
7LPRWK\ 0DUWHQ 0' )$C6
Founder and Director
Marten Clinic of Plastic Surgery
San Francisco, California, USA
*X\ *. 0DVVU\ 0'
Beverly Hills Ophthalmic Plastic Surgery
Beverly Hills, California, USA
Clinical Professor of Ophthalmology
University of Southern California
Los Angeles, California, USA
-XDQ 'LHJR 0HMLD 0'
Plastic Surgeon
Private Practice
Medellin, Colombia
Andreea Carmen Meruta, MD
Surgeon
Plastic Surgery Department
Centre Leon Berard
Lyon, France
Breast Institute
Monza Hospital
Bucharest, Romania
6WHSKHQ E. 0HW]LQJHU 0' 063+ )$C6
Clinical Associate Professor
Tulane University School of Medicine
Department of Surgery
Division of Plastic and Reconstructive Surgery
Aesthetic Surgical Associates
New Orleans, Louisiana, USA
-RKQ 5. 0LNORV 0' 06 )3506 )$C6
Director of Urogynecology and Cosmetic Vaginal Surgery
Miklos and Moore Urogynecology
Adjunct Professor of Obstetrics and Gynecology
Emory University
Atlanta Georgia, USA
Gabriele Miotto, MD, MEd
Assistant Professor
Division of Plastic and Reconstructive Surgery
Emory University School of Medicine
Associate Program Director
Aesthetic Fellowship at Emory Aesthetic Center
Atlanta, Georgia, USA
Robert D. Moore, DO, FACOG, FPMRS, FACS
Director, Cosmetic Vaginal Surgery
Beverly Hills Sunset Surgery Center International, Dubai
UAE
Miklos and Moore Urogynecology and Aesthetic Vaginal
Surgery
Atlanta, Georgia; Beverly Hills, California; Dubai, UAE
*LOO\ 0XQDYDOOL 0' 0+6 )$C06
Medical Director, Founder
Dermatology, Laser, and Vein Specialists of the Carolinas,
PLLC
Charlotte, North Carolina, USA
Farzad R. Nahai, MD
Board Certified Plastic Surgeon
The Center for Plastic Surgery at MetroDerm
Atlanta, Georgia
Foad Nahai, MD, FACS, FRCS (Hon)
Professor of Surgery
The Maurice J. Jurkiewicz Endowed Chair
Department of Surgery
Emory University
Atlanta, Georgia
9LF $. 1DQXUNDU 0' )$$' GHFHDVHG
Director and Founder
Bay Area Laser Institute
Chairman, Dermatology
California Pacific Medical Center
San Francisco, California, USA
Jonathan Nathan, MD, MBA
Plastic Surgeon
Private Practice
Chicago, Illinois, USA
Paula M. Neira, JD, MSN, RN, CEN
Clinical Program Director
Johns Hopkins Center for Transgender Health
Johns Hopkins Medicine
Baltimore, Maryland, USA
Stephanie Nemir, MD, PhD
Assistant Professor and Director of Breast Reconstruction
Department of Surgery
Paul L. Foster School of Medicine
Texas Tech University Health Sciences Center–El Paso
El Paso, Texas, USA

xxii
Contributors
0LFKDHO 3. 2JLOYLH 0' 0%$
Associate Plastic and Reconstructive Surgeon
Division of Plastic and Reconstructive Surgery
Advocate Christ Medical Center
Oak Lawn, Illinois, USA
Maria Cecilia Closs Ono, MD, PhD
Plástica and Craniomaxillofacial Surgeon
Adjunct Professor
University Federal of Paraná
Department of Surgery
University Federal of Paraná
Curitiba, Paraná, Brazil
CDUOR 0. 2UDQJHV 0' 3K'
Department of Plastic, Reconstructive, Aesthetic, and Hand
Surgery
Basel University Hospital
University of Basel
Basel, Switzerland
$P\ 3DWHO 0'
Department of Oculoplastics
Cedars-Sinai Medical Center
Los Angeles, California, USA
Nirav B. Patel, MD, MS, JD, FCLM
Associate Plastic Surgeon
Marietta Plastic Surgery
Marietta, Georgia, USA
CKULVWRSKHU .. 3DWURQHOOD 0' )$C6
Director, The Aesthetic Center for Plastic Surgery
Houston, Texas, USA
Clinical Professor of Surgery
Division of Plastic Surgery
University of Texas Medical Branch
Galveston, Texas, USA
IJRU 3HOOHJDWWD 0'
Plastic, Reconstructive and Aesthetic Surgeon
Private Practice
Milano, Lombardy, Italy
*DOHQ 3HUGLNLV 0'
Professor and Chair
Department of Plastic Surgery
Vanderbilt University Medical Center
Nashville, Tennessee, USA
Mauricio Perez, MD
Medical Writer and Editor
Department of Plastic Surgery
Dhara Clinic
Bogota, Colombia
Joel E. Pessa, MD, FACS
Clinical Research
Department of Medicine and Oncology
Heldermon Lab
University of Florida School of Medicine
Gainesville, Florida, USA
%\URQ '. 3RLQGH[WHU 0'
Medical Director
The Austin-Weston Center for Cosmetic Surgery
Reston, Virginia, USA
Jason N. Pozner, MD, FACS
Sanctuary Plastic Surgery
Boca Raton, Florida, USA
Adjunct Clinical Faculty
Cleveland Clinic
Department of Plastic Surgery
Weston, Florida, USA
Ali A. Qureshi, MD
Private Practice
Irvine, California, USA
Imran Ratanshi, MD, MSc, FRCSC
Attending Surgeon
The Plastic Surgery Group at City Centre
Department of Surgery
Fraser Health Region
Surrey, British Columbia, Canada
Rod J. Rohrich, MD, FACS
Clinical Professor of Plastic Surgery
Baylor College of Medicine
Past Chair, Distinguished Teaching Professor of Plastic
Surgery
Dallas, Texas, USA
Jason Roostaeian, MD
Associate Clinical Professor
Department of Plastic Surgery
David Geffen School of Medicine at UCLA
Los Angeles, California, USA
/RUQH .LQJ 5RVHQÀHOG 0' )$C6
Professor
University of California–San Francisco
Stanford University
Private Practice
Burlingame, California, USA
J. Peter Rubin, MD, FACS
Chair
Department of Plastic Surgery
UPMC Endowed Professor of Plastic Surgery
Professor of Bioengineering
University of Pittsburgh
Pittsburgh, Pennsylvania, USA

xxiii
Contributors
Sean Y. Saadat, MD
Plastic Surgeon
Plastic and Reconstructive Surgery
UCLA Health
Los Angeles, California, USA
Ara A. Salibian, MD
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Health
New York, New York, USA
Renato Saltz, MD, FACS
Adjunct Professor
Division of Plastic Surgery
University of Utah
Salt Lake City, Utah, USA
Sheena Samra, MD
Surgeon
Facial, Plastic, and Reconstructive Surgery
Lasky Clinic
Beverly Hills, California, USA
'DYLG %. 6DUZHU 3K'
Associate Dean for Research
Director, Center for Obesity Research and Education
College of Public Health
Temple University
Philadelphia, Pennsylvania, USA
.DWKDULQH 6DXVV\ 0'
Tulane Dermatology
New Orleans, Louisiana, USA
Loren S. Schechter, MD, FACS
Plastic Surgeon
Clinical Professor of Surgery
University of Illinois at Chicago
Attending Surgeon
Rush University Medical Center
Weiss Memorial Hospital
Morton Grove, Illinois, USA
0LFKDHO 6FKHÁDQ 0'
Plastic Surgeon
Scheflan Plastic Surgery
Tel Aviv, Israel
Alexandra C. Schmidt, MD
Plastic Surgeo
Private Practice
Blue Water Plastic Surgery Partners
Raleigh, North Carolina, USA
Gemma Sharp, PhD, MAPS, FCCLP
National Health and Medical Research Council Early Career
Fellow
Head of the Body Image Research Group
Clinical Psychologist
Monash Alfred Psychiatry Research Centre
Monash University
Melbourne, Victoria, Australia
.D\YDQ 6KRNUROODKL %6F 0% CK% 06F 05C6 EQJ
LLM, FRCS (Plast)
Professor
Consultant Burns and Plastic Surgeon
Mersey Regional Centre for Burns and Plastic Surgery
Whiston Hospital
Merseyside, United Kingdom
David A. Sieber, MD
Private Practice
San Francisco, California, USA
5REHUW .. 6LJDO 0'
The Austin-Weston Center for Cosmetic Surgery
Reston, Virginia, USA
6DPP\ 6LQQR 0'
Private Practice
Chicago, Illinois, USA
EPLO\ 6OXLWHU %6
Research Associate
Department of Surgery
Michigan Medicine
University of Michigan
Ann Arbor, Michigan, USA
Jacqueline C. Spitzer, MSEd
Senior Project Director
Temple University
Philadelphia, Pennsylvania, USA
'RXJODV 6. 6WHLQEUHFK 0' )$C6
Founder, New York Institute of Male Plastic Surgery
Co-Founder, Gotham Plastic Surgery
Attending Surgeon
Lenox Hill Hospital
New York, New York, USA
-H̵UH\ 7. 6WHLW] 0'
Facial Plastic and Reconstructive Surgery
St. Louis Facial Plastic Surgery
St. Louis, Missouri, USA

xxiv
Contributors
W. Grant Stevens, MD, FACS
Clinical Professor of Plastic Surgery
University of Southern California Keck School of Medicine
Director
Aesthetic Surgery Fellowship
Marina del Rey, California
James M. Stuzin, MD
Clinical Professor of Plastic Surgery (Voluntary)
University of Miami School of Medicine
Miami, Florida, USA
CKULVWRSKHU $. 7RNLQ 0'
Breast Surgical Oncology
Plastic and Reconstructive Surgery
Hawaii Pacific Health
Honolulu, Hawaii, USA
3DWULFN 7RQQDUG 0' 3K'
Medical Director
Coupure Center for Plastic surgery
Co-Director, Tonnard and Verpaele Associates
Ghent, Belgium
Dean M. Toriumi, MD
Professor
Department of Otolaryngology Head and Neck Surgery
Rush University
Chicago, Illinois, USA
-RQDWKDQ 7R\ 0' )5C6C
Associate Clinical Professor
Division of Plastic Surgery
University of Alberta
Edmonton, Alberta, Canada
Lina Triana, MD
Corpus y Rostrum Surgery Center
Cali, Colombia
6HUJH\ <. 7XULQ 0'
Division of Plastic and Reconstructive Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA
Alexis Verpaele, MD, PhD
Medical Director
Coupure Center for Plastic surgery
Co-Director
Tonnard and Verpaele Plastic Surgery Associates
Ghent, Belgium
:LOOLDP -. 9LQ\DUG 0' )$C6
Medical Director and Founder
Vinyard Institute of Plastic Surgery, LLC
Port St. Lucie, Florida, USA
Simeon Wall Jr., MD, FACS
Private Practice
The Wall Center
Shreveport, Louisiana, USA
Assistant Clinical Professor
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas, USA
Robert A. Weiss, MD
Assistant Clinical Professor
Department of Medcine, Gastroenterology
Mount Sinai Beth Israel
New York, New York, USA
*HRUJH :HVWRQ 0'
Senior Partner
The Austin-Weston Center for Cosmetic Surgery
Reston, Virginia, USA
David M. Whitehead, MD, MS
Assistant Professor of Surgery
Division of Plastic Surgery
Department of Surgery
Donald and Barbara Zucker School of Medicine at Hofstra/
Northwell
North New Hyde Park, New York, USA
7HG :RMQR 0'
Director, Oculoplastic and Orbital Surgery
Department of Ophthalmology
The Emory Clinic
Emory University School of Medicine
Atlanta, Georgia, USA
Blair A. Wormer, MD
Plastic and Reconstructive Surgery
Novant Health Presbyterian Medical Center
Charlotte, North Carolina, USA
0LFKDHO -. Clinical Professor of Surgery
Harvard Medical School
Director, Harvard Plastic Surgery Training Program
Chief of Craniofacial Surgery Massachusetts General Hospital
Boston, Massachusetts, USA
$QWKRQ\ Assistant Professor of Surgery
Oakland University William Beaumont School of Medicine
Youn Plastic Surgery, PLLC
Troy, Michigan, USA
.DUHQ $. =XSNR %6-
President
Karen Zupko and Associates, Inc.
Medical Management Consulting Firm
Chicago, Illinois, USA

xxv
Video Contents
Video Contents
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I
Part I
Fundamentals
Part I
Fundamentals

(Trang không có chữ)

1 The Patient
3
1 The Patient
Foad Nahai
Abstract
First impressions do count. The patient’s interaction with and
impressions of the surgeon’s website, staff, office environment,
and nurses, as well as the surgeon will significantly impact the
choice of surgeon. It is the overall experience that counts. Careful
attention to enhance and facilitate all facets of the patient’s
interaction with the surgeon and staff is essential.
Keywords
office and staff responsibilities, first consultation, patient
experience, patient financial responsibility, preoperative visit,
postoperative visit
1.1 A Well-Informed Patient Is a
Happy Patient
Our patients are bombarded with information about cos-
metic medicine and surgery; it is a pervasive theme in our
youth-oriented society, appearing in print, electronic, broadcast,
and, most prominently, on social media. Although some of the
information obtained from these sources may be helpful, much
of it is self-serving and intended to entice rather than enlighten.
Advertising and social media postings for aesthetic surgery are
calculated to bring patients into the surgeon’s office, often by
promising more than can be delivered while minimizing risks,
complications, and the possibility of unfavorable or suboptimal
results. :ebsites and social media devoted to cosmetic medicine
and aesthetic surgery often overload patients with information
promoting one procedure over another. Although the informa-
tion in itself is not detrimental, it can be confusing. Patients may
not have the medical background, experience, or sophistication
to sort through this material to make an informed decision. The
more conflicting the information they receive, the more confus-
ing it becomes, and often the more unrealistic their expecta-
tions. It is the surgeon’s responsibility to educate the patient by
presenting the facts in an unbiased manner. Even then, patients
may not be able to reach a decision and may rely on the surgeon’s
recommendations, trusting his or her knowledge and abilities.
It is this basic concept of trust that is being eroded through
the blatant marketing of aesthetic procedures and materials to
the public. The implication from this promotional activity is that
aesthetic surgeons are mere vendors of a commodity. Having a
breast augmentation is not like buying a bra or other piece of
lingerie, and a facelift is not like purchasing a high-end luxury
automobile, where one shops for the most convenient dealership
or the best discounts. Nothing could be further from the truth.
:e are not selling a product; we are providing a service³a
service that is personal and customized to each patient, one that
carries risks unlike those encountered at the beauty salon or spa.
This is a high-end service that encompasses the entire patient
experience. This experience begins with the patient’s initial on
line search and viewing of social media postings and the physi-
cian’s website (Fig. 1.1), leading eventually to a telephone inquiry
or an electronically scheduled appointment. It progresses through
encounters with the receptionist, patient coordinator, nurse, and
surgeon, and culminates in the surgical procedure. The success
of this experience has traditionally been strongly dependent on
the surgeon’s skill, experience, and judgment. Today the surgeon’s
skill in managing social media may well be as important.
1ot all surgeons have the same experience, medical knowledge,
training, surgical expertise, or technical ability. The well-informed
patient should choose a surgeon based on trust³not on hype,
social media presence, or cost.
1.2 The First Consultation
The decision to seek cosmetic treatments or aesthetic surgery is
usually not spontaneous. Most likely the patient contemplated
this possibility for months, if not years, before looking online
and picking up the phone to make an appointment with a plastic
surgeon. Some patients may have extensively researched the
procedure, the surgeon, and the surgeon’s practice through the
Internet, social media, and, in particular, the surgeon’s website.
Even today, others rely solely on the recommendations of friends
and family. These recommendations are best when based on
personal experience. Satisfied patients are the ideal source of
referrals and are far more valuable than any advertising, pro-
motions, social media presence, or even the best marketing that
money could buy.
The initial consultation does not necessarily begin with the first
phone call to schedule an appointment. Most likely the prospec-
tive patient has already visited the practice’s website, and the first
contact may have been through the website (Fig. 1.1).
Fig. 1.1 Your website is the face of your practice to the world.

4
I Fundamentals
1.2.1 The First Telephone Contact
The website and the first telephone contact leave a lasting impres-
sion with the patient; if those contacts are unfavorable, the patient
may decide against making an appointment or fail to keep it. Prompt
responses to the patient’s inquiry through the website and proper
telephone etiquette are of utmost importance. The phone should be
answered after a maximum of five rings, and the voice that greets
the caller should be cheerful and inviting, announcing the name
of the practice and the name of the person answering, followed by
´How may I help you"µ This greeting should be spoken in a clear,
understandable voice. Such an encounter will leave the caller with
a positive impression. Conversely, an unfavorable impression may
be left when the phone is answered by a programmed voice reeling
off a list of options, each requiring a separate button to be pushed,
until the irritated caller is either disconnected or put in touch with
the appropriate person. This type of impersonal answering system
can alienate potential patients. By the time the annoyed caller
actually reaches a live person, she or he is no longer in any mood
to discuss aesthetic surgery. In any high-end service, immediate
contact with a caring individual is essential.
In most offices, the caller is first connected with the person respon-
sible for scheduling appointments. This person must understand
the importance of flexibility, even for surgeons who are fortunate
enough to have large practices with few immediate openings for new
patients. Impressive as it may sound to inform a patient that there
are no openings because the surgeon is fully booked for 18 months or
longer, in most cases this will only encourage the prospective patient
to look elsewhere. :e live in a world where everyone is busy. Most
of our patients value their time as we do and have only specific days
and times when they can afford to miss work for a doctor’s appoint-
ment. This is particularly true for those seeking aesthetic surgery,
who usually do not wish to ask for sick time or announce to their
supervisor that they are going to see a plastic surgeon.
Although we may not always be able to accommodate every
patient’s scheduling needs for every office visit, it is important to
do so for the initial consultation. For this reason, some practices
offer evening and Saturday office hours. Patients should be asked
how soon they would like to schedule the appointment. Then every
effort should be made to schedule the appointment as close to that
date as possible without overcommitting the surgeon, yet leaving
sufficient time for the initial consultation. (In my practice, at least 1
hour is allotted.) Although patients assume that doctors are never
on time, patients still make every effort to arrive as scheduled. It is
a matter of common courtesy, whenever feasible, to see patients at
the appointed time. Obviously, this is not always possible. It is good
practice, however, to notify patients if you are running late, either
before they arrive, if possible, or on their arrival.
The scheduler should record the caller’s name, address, and contact
information. It is also important to inquire about the reason for the
consultation. Some individuals may be reluctant to disclose this infor-
mation to a stranger on the phone. The scheduler should explain that
while patient privacy is of the utmost importance, these questions
are being posed to determine whether the practice offers the proce-
dure that the patient is seeking. It also provides valuable information
for the surgeon to help prepare for the patient’s initial consultation
and to ensure that sufficient time is allotted for that appointment.
Patients seeking removal of a skin lesion may not require as much
time at the initial visit as someone seeking facial rejuvenation.
Once the appointment is made, patients are told that a package
will be mailed to them or can be downloaded from the website.
Most practices now offer patients the option of filling out their
initial paperwork online, thus eliminating the need to do so in
the doctor’s waiting room during the initial visit. Some patients
may not want to receive mail, phone calls, faxes, emails, or other
communications that are identified as coming from a plastic sur-
geon’s office. Special care should be taken to cater to these needs.
The scheduler should ask where the patient would like to receive
correspondence from the office. Some thought should be given
to using envelopes and fax cover sheets without any indication
that communications are coming from a plastic surgeon’s office;
envelopes should have a street address without a practice name or
logo. In the interest of patient confidentiality, the scheduler should
also specifically ask patients how they wish to be contacted by the
practice³for example, by home, cell, or office phone or by email.
The information package sent from the office should include
general information about the practice; maps and directions, spe-
cific information about the surgeon, including qualifications and
practice philosophy; a letter detailing what will happen during
the initial consultation; and a brochure on the procedure the
patient is seeking. Most, if not all, of this information is probably
already available on the surgeon’s practice website. However, it
is important to remember, even today, that not all patients are
Internet-savvy, and some may prefer a hard copy; therefore the
printed material serves as a reliable resource for all patients
regardless of their technical know-how.
Maps and directions to the surgeon’s office should be sufficiently
detailed to allow patients to locate the office easily. Parking should
be ample and convenient. Any special parking instructions should
be detailed in the information package. Even though a patient is
looking forward to the visit with the plastic surgeon, this initial
consultation is a stressful event; getting lost or frustrated over
finding a parking space will merely add to a patient’s anxiety.
An example of the type of patient letter that is sent with our
practice information package is shown in Fig. 1.2.
1.2.2 Contact with the Receptionist
The patient’s first face-to-face encounter in the surgeon’s office
will be with the receptionist, who should greet the patient and
notify the patient coordinator or nurse of the patient’s arrival. It is
disconcerting for a patient to walk into the surgeon’s office for the
first time only to find that no one is there to greet him or her; even
worse is when two or three staff members are engrossed in con-
versation or occupied on the telephone and the patient is ignored.
It is also essential that we respect the patient’s privacy during
this sign-in process; several points merit particular attention:
• Sign-in lists where the patient signs his or her name under the
name of the previous patient should be avoided.
• The receptionist should sit in an enclosed space, preferably
in a glass-enclosed area, to maintain privacy yet allow the
receptionist to have full view of the waiting room.
• The receptionist or nurse should refrain from loudly announc-
ing the patient’s name in the waiting room.
• Under no circumstances should the patient be greeted with
such words as ´enlargement"µ

1 The Patient
5
• In most states in the United States and in some other countries,
the practice is required to display a Patient’s Bill of Rights and
the privacy statement.
Once a patient has signed in, he or she should be told when to
expect to be taken to the consultation room to meet with the
patient coordinator. If there is a delay, the patient is given an
estimate of the waiting time, and coffee or a soft drink can be
offered. :henever possible, an explanation is provided for the
delay. If the delay is inordinate or unacceptable, the patient is
offered the choice of rescheduling or waiting. Very rarely, if I
am running unacceptably late³a half hour or more³the fee for
the initial consultation will be waived and the patient’s parking
charges paid as a gesture of goodwill.
1.2.3 Contact with the Nurse or Patient
Coordinator
The patient is then escorted to one of the examination rooms.
In my practice, the nurse meets with the patient first. A history
is taken, and the completed health questionnaire, which the
patient has downloaded from the website or received in the
mailed package sent out before the initial office visit, is reviewed.
An overall personal history questionnaire (Fig. 1.3) and general
intake information sheet (Fig. 1.4) must be filled out.
At this time the patient usually discusses the reason for the
consultation with the nurse. This takes from 10 to 20 minutes,
depending on the patient, the nurse, and the procedure. I then
review this information before meeting with the patient.
1.2.4 Contact with the Surgeon
I greet the patient, introduce myself, and immediately ask, ´:hat
can I do for you"µ :e then discuss the patient’s goals and what
he or she hopes to accomplish through aesthetic surgery. 1ext
we review the patient’s history, including pertinent information
on general health and specific information concerning previous
aesthetic treatments, procedures, and skin care.
Procedure-specific information is discussed in detail. For exam-
ple, patients desiring eyelid work are asked about any history of
eye problems such as dry eyes, glaucoma, or risk factors for the
latter, such as high blood pressure or family history (Fig. 1.5).
Any woman desiring breast surgery is asked specifically about
her family history of breast disease, including cancer, history of
breast masses and biopsies, mammography, and childbearing
history (Fig. 1.6). If the patient is contemplating liposuction or
body-contouring procedures, we discuss lifestyle, exercise, nutri-
tion, and weight control (Fig. 1.7). For abdominal procedures, we
discuss previous abdominal operations, including liposuction and
hernia surgery. For facial rejuvenation procedures, I ask whether
patients are currently smoking, but I am also interested in their
smoking history³that is, whether they have ever smoked, for








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Fig. 1.2 Patient letter.
Fig. 1.3 Personal history questionnaire.

6
I Fundamentals
how long, how heavily, and whether and when they stopped. I
ask about previous aesthetic procedures, including injectable and
noninvasive treatments. I question all patients about a history of
phlebitis or deep venous thrombosis (DVT).
Once the history has been reviewed, I return to the reason for
the consultation. Throughout this consultation, I know that the
patient is assessing me as a person, a physician, and a surgeon.
Clearly, he or she has no way of realistically evaluating my knowl-
edge of aesthetic surgery or my technical abilities. In all likelihood,
patients will base their decisions on my demeanor and how warm,
caring, and attentive I appear³my ´bedsideµ manner. Meanwhile,
I am assessing the patient. Are his or her goals realistic" :ill I be
able to meet these goals" Do I like the individual" If we have a
complication, will I be able to maintain patient confidence while
we resolve the problem" I am particularly attentive to the patient’s
body language, eye contact, tone of voice, and most of all, his or
her enthusiasm and interest during the consultation. I observe the
patient’s appearance, hairstyle, makeup, clothing, and accessories.
These not only reflect the patient’s tastes but also attention to
detail and how exacting the individual will be as a patient. I am
concerned when an individual who is sloppily dressed and poorly
groomed comes in seeking aesthetic surgery. In a similar manner,
the appearance and grooming of the surgeon leaves an important
impression about the surgeon’s attention to detail and the care
and meticulous surgical technique that he or she offers to each
patient. I certainly would be hesitant to let any sloppily dressed or
poorly groomed physician or nurse take care of me
It is not unusual for patients to come in after researching the
procedure on the Internet or on other physicians’ websites. In all
likelihood they have sought consultation elsewhere as well. They
may have been given conflicting advice and information, which
they may or may not share with me. Close to the end of our con-
sultation, I now ask them whether I have told them anything that
they were not aware of or anything that conflicts with information
they may have found or been given elsewhere.
Most patients respond that they were aware of some but not all
of the information that we provided. In my experience, this new
information is almost always related to expected outcomes and
complications. It amazes me that even today I see patients who
have researched breast augmentation on the Internet and have
had consultations elsewhere, but may not be aware that breast
implants are not permanent.
I never pressure patients to make a decision during the initial
visit. In fact, I encourage them to ask questions, take home the
materials we provide, and return for a second visit, which is
complimentary, before making a final decision. However, we
do arrange for our patient coordinator to quote fees and discuss
scheduling during this first visit.
I follow up every new consultation with a personal letter
rather than a form letter, summarizing our discussion and a brief
Fig. 1.4 General intake information.
Fig. 1.5 Blepharoplasty questionnaire.

1 The Patient
7
description of my recommendations and points that need to be
stressed, such as that shown in Fig. 1.8; I remind patients that
I would be happy to meet with them again before they make a
decision or schedule a procedure.
1.3 Motivation
A well-motivated patient is a happy patient. Understanding
patient motivation is an essential goal of the initial consultation.
4uestions probe the reasons for seeking surgery. For whom is
the patient pursuing the operation³is it to please someone else"
Does the patient think that this will change his or her life" The
best patients are those who are seeking surgery for themselves
so they can look and feel better in their own eyes. The best
motivation is self-improvement. :ith most patients, I am able to
understand what motivates them after a few minutes. Sometimes
I will ask patients whether they hope that the aesthetic surgery
will change anything in their lives and inquire as to whose idea it
was for them to have this procedure.
Almost always, teenagers seeking rhinoplasty or other aesthetic
procedures suitable for their age are accompanied by a parent. I make
it a point to address the teenagers directly and have them, rather than
the parent, tell me what they would like. I usually tell them that they,
not their parents or their surgeon, will have to live with the result, so
they need to carefully consider what they are requesting. Although I
will allow the parents to express their opinions, I make it clear to the
patients that they should make the final decision.
Patients often have hidden agendas³secret and personal rea-
sons for seeking this procedure. They are reluctant to share this
with the surgeon, the staff, or even their family and friends. These
hidden agendas may include attracting a significant other, seeking
a promotion, or simply responding to a life-altering event. Beware
of this hidden agenda, because even if the procedure yields an
excellent result, these patients will never be happy unless the
requirements of the hidden agenda have been fulfilled.
1.4 When to Say No
1ot every person I see is a candidate for a surgical procedure.
I classify noncandidates into six general categories, as follows:
1. Those seeking the procedure before they are ready for it (for exam-
ple, breast augmentation for teenagers, facelifts in women who do
not need them or who will see little difference, or rhinoplasty in
12-year-olds)
2. Those with unrealistic expectations (for example, those patients
who believe that aesthetic surgery will ´change their lives,µ save a
marriage, or make them look like swimsuit models or movie stars)
3. Patients on whom I would prefer not to operate (for example,
those who are overly demanding, noncompliant, abusive to
office staff, or ´aesthetic surgery junkiesµ)
Fig. 1.6 Breast surgery questionnaire.
Fig. 1.7 Body contouring questionnaire.

8
I Fundamentals
4. Another surgeon’s unhappy patient who has a reasonable result
but remains extremely critical of the original surgeon
5. Patients who are psychologically unstable
6. Those who are seeking to improve on problem areas or imperfec-
tions that are not readily recognized by others; these individuals
may well have body dysmorphic disorder (BDD)
Patients in group 1 are counseled that it is too early for the pro-
cedure they are seeking. I explain to these patients that I would
like them to be my patients and that I will operate on them at
the appropriate time. A woman seeking a facelift before she is
truly ready will be offered skin care, other ancillary procedures,
and injectables, if appropriate, until she is ready for a surgical
procedure. I explain to teenagers seeking augmentation that it
is best to wait until their breasts have stopped growing. Beyond
that, there are Food and Drug Administration (FDA) restrictions
to consider. I will make an exception for teenagers with signifi-
cant breast asymmetry and promise the 12-year-old that as soon
as her nose is fully grown, we will take care of it.
I explain to patients in group 2 that I do not believe I can
provide them with the result they are looking for or meet their
expectations. I also let them know that I am concerned that they
will be unhappy or displeased with me.
Patients in group 3 require special tact. I tell these demanding
patients that I do not believe that our office will be able to provide
them with the level of service that they are seeking. To the abusive
patient I explain that the office staff and I are a team and, because
the patient has already indicated an unwillingness to work with
my office staff, I cannot care for this individual because I will not
work without my colleagues. Finally, to the patient who has an
insatiable desire for plastic surgery, I say, ´it is too early to have any more.µ
Dissatisfied or unhappy patients in group 4 are told that they
have had a reasonable result, that they are being unduly tough on
their previous surgeon, and that I doubt I can significantly improve
on what has been done. My major concern is that a patient with
an average result who is trashing the original surgeon will one day
say the same about me, regardless of the result. Any patient who
walks in and unjustifiably claims that they were ´butcheredµ or
´mutilatedµ is an immediate noncandidate.
Group 5 includes psychologically unstable patients whose
instability is not always readily discernible. I advise them to seek
counseling and treatment before considering aesthetic surgery.
In fact, anyone under psychiatric care at the time of consultation,
regardless of my own personal impression of his or her suitability,
is referred back to the psychologist or psychiatrist for clearance
before scheduling. It is not uncommon today to see patients who
are taking antidepressants such as fluoxetine (Prozac) or bupro-
pion (:ellbutrin). This by itself does not disqualify them, as long
as they are stable individuals. Most of the time the antidepressants
have been prescribed by their internist or family physician for mild
depression rather than for any severe psychiatric condition. Most
of these individuals are suitable candidates for aesthetic surgery.
Group 6 individuals may appear normal to the untrained; how-
ever, their insistence that a small blemish or minimal deviation
from the norm is a major deformity that is ruining their lives and
incapacitating them is an indication of BDD. These individuals
should be referred for counseling. Surgical or other procedures on
these patients lead to further dissatisfaction, disappointment, and
anger. Extreme caution should be exercised in handling this group.
I discuss the options available to the patient and make my
recommendations. I explain that I prefer to operate in our ambu-
latory surgical center, which is certified and inspected by the -oint
Commission on the Accreditation of Healthcare Organizations
(-CAHO, or simply -oint Commission) and the state of Georgia. I
tell patients that anesthesia will be provided under the supervi-
sion of a board-certified anesthesiologist and that I personally will
perform the entire operation. I explain that they will be charged
for the consultation that day, and if I operate on them, they will
be expected to prepay for the surgery. All follow-up visits before
and after the operation are included in the charges for the surgery.
I do not discuss specific fees and charges; our patient coordinator
does that. I do, however, explain to patients that I will perform
revisions, if needed, at no additional charge. Although rare, should
a complication necessitate the services of other physicians or hos-
pitalization, those expenses would be the patient’s responsibility.
his patients on this subject. I still use a modified version (Fig. 1.9),
which patients are asked to read and sign before surgery.
However, my no-charge policy for revisions does not always
apply to liposuction patients, who often return seeking revisions
and repeat liposuction after weight gain, thereby obviating the
results of the original procedure. To avoid future misunderstand-
ings, we talk to these patients preoperatively about the impact of
weight gain on long-term liposuction results. Liposuction patients
Fig. 1.8 Follow-up letter to prospective breast surgery patient.

1 The Patient
9
are asked to read and sign an additional form regarding weight gain
and repeat procedures (Fig. 1.10) so that they fully understand that
additional liposuction after a substantial weight gain (10 pounds
or more) will not be considered a revision but a new procedure.
1.5 Surgeon Shopping
Currently the public is being advised to seek two if not more
consultations before selecting a plastic surgeon, so most
patients will see at least one another surgeon before proceeding.
Although a second or third opinion is not unusual today, I would
be wary of patients who have seen numerous plastic surgeons.
Occasionally a patient comes in with an information package and
video images from another practice and a file full of information
and images downloaded from the Internet. Sometimes the
patient tells me that a different procedure was recommended by
others. This in itself is not a red flag to me, but it requires extra
time and discussion. I explain that each surgeon will recommend
an operation that, in his or her hands, comes as close as possible
to the patient’s desired goal. I assure the patient that I have done
the same. The fact that my recommendation differs from that of
the other surgeon (or surgeons) does not necessarily mean that I
am correct and the other surgeons are not; it simply means that
I have recommended a procedure that, in my hands, would give
the patient the best result.
I tell patients who have seen other surgeons that they should
not base their choice of physician on price, on who has the fanciest
or sparsest office, or on convenience of location. Rather, the choice
should be based on the overall impression of the physician and
the office staff, rapport with them, and most of all, confidence and
trust. I explain to patients that, even in the best of hands, compli-
cations are possible, and that they should have enough confidence
and trust in the surgeon they choose to allow him or her to handle
any problems through to resolution. Patients often make the
mistake of going to another physician once they have developed a
complication, even though the original surgeon would be equally
capable of dealing with it. These patients often blame themselves
and are convinced that they made the wrong choice. I tell them
that if they choose me, they should have enough confidence to
allow me to handle any complication unless I recommend that
they see someone else.
1.6 Patient Education
I discuss outcomes, risks, and complications with the patient
during the initial consultation. All are informed that all
procedures carry risks and that cosmetic treatments and
aesthetic surgery are no exception. I explain that the risk of
a life-threatening complication is not greater than the risk
of flying³and significantly less than that of driving around
Fig. 1.9 Agreement concerning fees.
Fig. 1.10 Agreement concerning liposuction revisions.

10
I Fundamentals
Atlanta. Once the patient is reassured in terms of general risks,
I address specific risks. All of my patients are told that infection
and bleeding are common risks to all aesthetic procedures but
are extremely rare. I do prepare them for postoperative bruising
and swelling, which may accompany any cosmetic procedure
or aesthetic operation. I explain to all facelift patients that in
my hands the most common complication is hematoma, and the
risk is currently below 1; the risk is higher in men, in persons
with uncontrolled high blood pressure, and in anyone who is
troubled by postoperative nausea and vomiting. I tell them
that every precaution will be taken to minimize the risk, but it
cannot be eliminated entirely. I add that the risk of permanent
nerve damage is extremely rare³on the order of 1 in 1,000 cases
or less. I inform them that all surgical procedures leave scars
and that the quality of the scar reflects not only the surgeon’s
skill (most patients believe that scars are related solely to the
surgeon’s skill and that plastic surgery leaves no scars) but also
the patient’s body chemistry, location of the scar, and tension. I
stress that we can improve on any obvious, unsightly, or unac-
ceptable scar through conservative means, and a scar revision
can be done, if needed, at no additional charge.
I also explain to my patients that although serious complications
are rare, revisions may sometimes be necessary. I will reoperate on
a patient whose result falls short of my own expectations as well
as those of the patient. These revisions are at no cost to the patient.
However, if I feel that the result is the best I can achieve and the
patient is still dissatisfied, then I recommend a second opinion. In
addition to my explanations, the patient coordinator also reviews
the more common complications associated with each procedure,
such as capsular contracture, implant failure, and nipple and are-
olar sensory changes following breast augmentation. Eventually
patients also receive a letter and informed consent form, which
they are asked to read, initial on each page, and sign on the last
page. These documents enumerate the complications.
:e also discuss postoperative management, including an over-
night stay in our suites if needed, the frequency of postoperative
visits, restriction of work and other activities, and the expected
time to full recovery. I do not minimize the length of time needed
for complete resolution of all bruising and swelling. I tell all facelift
and blepharoplasty patients that it may take up to 5 weeks for
them to look ´normalµ without makeup.
My first encounter with the patient lasts from 15 to 30 minutes.
After that the patient is sent to the photography room, where our
professional photographer will do the video imaging. I have found
video imaging to be very helpful with facial aesthetic procedures,
rhinoplasty, and breast augmentation. Video imaging is not rou-
tinely offered to our body contouring patients, although there is
now some new software that may well make video imaging for
body contouring as reliable as it has been for the face and nose.
Three-dimensional imaging, though currently very expensive,
may one day contribute further not only to video imaging but also
to preoperative and postoperative evaluation of results.
All patients are given the opportunity to review our preop-
erative and postoperative album. Most will have already seen
similar images on our website. It is not unusual for patients to
base their decision even to come in for a consultation on the
before and after images that are posted on the website. Without
exception, we show preoperative and postoperative breast reduc-
tion and mastopexy images so that the patient will have a clear
understanding of the location of the scars. After the video imaging
session, I review the projected result and discuss with the patient
whether that result is realistic and how close we can approximate
it. 1o promise or implied guarantee of a result is made. At this
time the preoperative and postoperative album is reviewed with
the patient if needed. Usually it is the patient coordinator and
the photographer who show the album to the patient. We do
encourage our patients to bring in photographs to demonstrate
what they like. For example, rhinoplasty patients bring in images
of noses that they like and those they do not; the same is true
for breast augmentation patients. Reviewing these images with
the patient provides me with further insight into the patient’s
aesthetic goals. For facial rejuvenation patients, we ask that they
bring in photographs taken 5, 10, and even 15 or 20 years earlier
so that we can better assess their features.
At the end of the consultation, the patient spends additional
time with the patient coordinator, who will discuss fees, schedul-
ing, and the preoperative routine. The coordinator again describes
the procedure, risks, likely outcomes, and expected recovery. If
an overnight stay is planned, an album containing images of our
overnight suites is shown to the patient. Occasionally the patient
will ask to see the operating rooms and overnight suites. If there
is an unoccupied overnight suite and the recovery room is empty,
we will accommodate this request. A video tour of our facilities is
also available on our website.
Most patients will, in fact, schedule, or at least ask to have time
reserved, at that initial visit. :e do encourage them to think about
things and offer them a return visit before they schedule or the
option to schedule by telephone.
1.7 Financial Responsibilities
Although the major source of patient dissatisfaction is a result
that does not meet expectations, financial misunderstandings
and problems with fees are also common sources of patient
anger. Far too many patients who were initially happy with their
excellent results become dissatisfied and find fault with their
results if unexpected charges appear long after the operation has
been completed. Financial surprises should be avoided if at all
possible.
My patient coordinator clearly delineates the patient’s finan-
cial responsibilities during the initial visit. The patient is given
an itemized quote that includes the surgeon’s fee, facilities fee
(including anesthesia), charges for an overnight stay, and any
implantable devices. It is also made clear that if other procedures
are added between the time the patient has prepaid for the
procedure and the actual operation, there will be additional fees.
The coordinator also explains that if any specimens are removed
(such as moles, breast tissues, or breast implants) and sent to the
pathologist, there will be a separate bill from the pathologist. We
cannot provide them a quotation for the pathologist’s services;
this must come from the pathology laboratory.
In our own surgicenter we do not charge the patient extra if a
planned procedure takes longer than anticipated. However, this
may not be the case if the procedure is scheduled elsewhere.
Far too many patients have prepaid for a 4-hour procedure in a
hospital-based surgicenter only to be billed later for extra time
when the procedure runs long. Under these circumstances it

1 The Patient
11
should be made clear to the patient that although the surgeon’s
fee is prepaid in full, the surgicenter facility fees are only an esti-
mate, and the actual amount will vary according to the length
of time, materials, and equipment used in the surgicenter. The
patient may, in fact, receive a bill for the balance several days,
weeks, or even months after the procedure. If this policy has
been clearly explained, patients are less likely to be dismayed
and upset.
Another cause of confusion about financial responsibilities
concerns cases in which a combination of aesthetic and recon-
structive procedures is performed (for example, nasal airway
surgery and cosmetic rhinoplasty or second-stage breast
reconstruction combined with aesthetic facial surgery or body
contouring), where a third party is responsible for the recon-
structive portion and the patient for the aesthetic portion. It may
sometimes be difficult, if not totally impossible, to delineate the
patient’s financial responsibility exactly for these procedures. :e
have a person in our practice who meets with patients to discuss
insurance coverage and such financial problems. Despite all of
these efforts, patients must understand that the total cost of all
of these combined procedures and their specific financial respon-
sibility may not be determined until long after the procedure. If
patients are prepared for a possible financial surprise, they are
less likely to become angry and find fault with the result. The
patient coordinator and I also discuss financial responsibilities in
case of complications, hospitalization, or consultation with other
physicians.
1.8 Operating on Colleagues,
Friends, and Family
As a practice is built and a reputation is gained, colleagues,
coworkers, friends, and family will seek your services. This
is a tremendous compliment to you as a physician and to your
skills as a surgeon. Although this is flattering, the surgeon
should understand that it can also be a significant financial
drain, because this group of patients expects discounted or even
complimentary surgery. 1ot only do such discounts and compli-
mentary procedures generate little or no revenue to help meet
overhead and malpractice costs, but also the time spent on such
discounted procedures could have been spent on patients who
produce full revenue. Despite this, most surgeons have a sense of
obligation to discount services for this group or to provide them
selectively on a complimentary basis. a clear policy for such discounts and free services.
I routinely discount my surgical fee for fellow physicians and
their families, nurses, and other health care professionals. The
amount of the discount will vary, depending on the closeness of
my professional relationship with the individual in question. The
same is true in dealing with friends and family. Some colleagues
and family come in for a consultation expecting to pay full fees,
yet others come in expecting free surgery. It is somewhat embar-
rassing, if not difficult, to discuss this face-to-face with colleagues,
friends, and family. note that he had colleagues, friends, and family read explaining
his policy for extending professional courtesy. I found the letter
most useful, and to this day I use the modified version shown in
Fig. 1.11.
For our office staff, the procedures are usually provided free
of charge on an individual basis, reflecting the person’s length of
service. Each practice should have a clearly delineated policy on
employee discounts. It is wise to avoid providing discounted or
free operations to patients who hold out the promise of future
referrals. These usually do not materialize once the operation has
been completed and may well raise ethical issues.
1.9 Patient Documentation
I make every effort to dictate the office notes as soon as I have
concluded the initial consultation. Although I take additional
notes while I am talking to the patient, I make every effort to
maintain eye contact with my patient rather than spending
the entire time scribbling notes or being preoccupied with the
computer and the electronic medical record. If at all possible, I
limit interruptions to those that are absolutely necessary, such
as emergencies. I put my cell phone on vibrate mode and ask
all our nurses to do the same. It is not conducive to a thorough
initial evaluation to have constant interruptions, and I will not
leave a patient while I answer a phone call unless it truly is an
emergency. It is important to sit down with the patient and focus
your attention on him or her. that you have plenty of time to talk. Therefore I do not look at my
Fig. 1.11 Letter presenting policy on discounted and complimentary
services.

12
I Fundamentals
watch or time myself when I am with a patient. I like to have a
nurse or assistant present in the room at all times, and I feel it is
advisable to have a female nurse or assistant with me when I am
in a room with a female patient and mandatory when I examine
a female patient for breast augmentation or body contouring, not
only to put the patient at ease but also for my own protection.
Once the procedure is scheduled, the patient is given instruc-
tions in preparation for the operation. These include prescriptions
for skin preparation before chemical peels and laser resurfacing
and lists of medications and supplements to avoid taking
pre-operatively to minimize postoperative bleeding and bruising.
:e encourage patients to take vitamin C. Patients are scheduled
for a preoperative visit 1 or 2 weeks before the operation. Patients
who will undergo general anesthesia need to have a physical
examination, blood test, and clearance from their primary phy-
sician before surgery is scheduled. During the preoperative visit,
the patient will meet the anesthesiologist, who performs another
preoperative evaluation. The patient also meets again with the
coordinator to review and sign the informed consent form and to
have any further questions answered. If preoperative photographs
have not already been taken, they are taken on this occasion.
During this preoperative visit, the patient talks with our financial
counselor, who goes over the fees and collects prepayment for the
full amount of the procedure, including the surgeon’s fee, facility
fee, and fees for the overnight stay and materials. If there is any
question about whether additional payments may be necessary
after the operation, such as a pathologist’s bill, this is clearly
pointed out to the patient.
The patient will be evaluating the level of service before the pro-
cedure, because it serves as an indication of how well the practice
will respond to her or his needs and concerns after the operation.
If the patient feels that the staff were not attentive enough, were
slow to respond, or were evasive before the operation, he or she
will be concerned that this may well be what they should expect
after the operation. Unfavorable preoperative experience may
justifiably lead the patient to cancel the procedure.
On the day of the operation, I review the patient’s record before
I meet with the patient to discuss the planned procedures. I
take my own finger or a cotton tip applicator and go over every
proposed incision. I then mark the patient. If he or she is accom-
panied by a family member and allows that person to remain in
the room, I ask the patient and the family member if they have
any questions and inquire whether the patient remembers the
risks, possible complications, and length of recovery. It is not
unusual for patients at the last minute in the preoperative area
to ask whether we could take off skin lesions, add an extra area
for liposuction, or even add a completely new procedure. For
that reason, and to avoid any postoperative misunderstandings, I
confirm with the patient that we have neither left out any proce-
dures nor added anything. I explain that if the patient wishes to
add extra procedures and operative time is available, there will be
an extra charge, and the patient will be billed for it. If he or she
requests excision of a skin lesion or two or a small additional area
for liposuction or fat injection, I often as a courtesy include that
without extra charge. However, I mention that the pathologist will
send a bill for examining the excised lesions.
We then proceed to the operating room. There is a special wait-
ing area for family members if they choose to wait; if not, I ask for
a phone number so that I can personally call when the operation
is finished and the patient is in the recovery room. I also inform
the patient and the family that if the operation is completed in less
time than I had allotted, it does not mean that I rushed through it,
and conversely, if it takes longer, it does not mean that either the
patient or I encountered a problem.
After the operation, patients either go home with a responsible
adult or stay in our recovery suites. If the patient goes home, I call
that evening to inquire whether the patient is comfortable and
whether there are any questions. If I am greeted by the answering
machine, I leave a message that I called to make sure that the
patient is home and comfortable. I ask the patient to call if there
are questions or problems. If the patient remains in our suites,
either I or someone on the team visits the patient. Two days post-
operatively, all patients receive a follow-up phone call from our
surgicenter asking them how they are doing and inquiring about
their experience with the center.
1.10 Postoperative Visits
Follow-up visits are as important as the initial consultation.
Most patients are concerned that the red carpet and VIP treat-
ment will be rolled out preoperatively so that they will sign up
for an operation, and that their postoperative care will be less
attentive, relegated to the nurses. It is important for them to have
a favorable experience in their postoperative visits. :e make
every effort to usher postoperative facial patients straight into
a private waiting room or examination room to minimize their
time in our public places, such as the general waiting room. I go
in and sit and greet the patient, ask how he or she has been, and
how the recovery is progressing. I explain that the nurses will
clean the wounds, remove sutures, and change tapes, and that
our aesthetician will take care of the areas that may have been
resurfaced. I inquire whether the patient needs more medication
and explain that I will return for a more thorough examination
once the nurses have removed sutures and cleaned the wounds.
As with preoperative examinations, a nurse is present during
the postoperative examination of a breast augmentation or body
contouring patient, to put the patient at ease and for my protec-
tion. It is important to close the door, sit down, make eye contact,
and talk to the patient. I do not focus on the computer screen to
read through it or write in it. Leaving the door open, standing,
reading, and writing leaves the patient with the impression that
you breezed in for a few seconds, clicked something in the chart,
and left without examining him or her. :hen I return to see the
patient, I examine every suture line and express my own opinion
about the early results and stage of recovery. I then answer ques-
tions. If the patient is at the stage in a facial procedure where
camouflage makeup can be applied, our aesthetician applies
makeup, and I see the patient after this application. For patients
who have undergone breast augmentation or body contouring
procedures and have recovered sufficiently, I go back in and see
them when they are fully dressed to make certain they are happy
with their appearance in their clothes.
Occasionally, despite my best efforts, a patient complains to the
nurse that I have not been attentive enough or spent enough time
after the operation. This is an important line of communication
between the patient and me, and I listen to the nurse and make
every effort to resolve the situation. Very often a patient who is

1 The Patient
13
concerned about the result may discuss it first with the nurse or
patient coordinator for fear of offending the surgeon: ´I don’t want
to hurt his feelings.µ These communications are important and are
dealt with in a kind and understanding fashion. I explain to my
patients that I want them to be comfortable and open with me
and discuss their concerns. My feelings will not be hurt if I am told
that a patient is less than satisfied with the result. I tell patients
that my feelings would be hurt if they felt that they couldn’t com-
municate with me and chose to go elsewhere.
I rely heavily on the impressions of our nurse and patient coor-
dinator. It is crucially important to surround yourself with good
people and to listen to them. I have turned down patients based
on recommendations from these professionals and have been able
to defuse potentially unpleasant situations based on their input.
1.11 Management of Complications
and Problems
1o one wants complications. I take all complications personally
and replay the entire procedure in my mind, wondering how and
why they occurred. Despite my explanations to my patients that
complications do occur, even in the best of hands, it is difficult
for me to accept that my patient has developed a complication.
Regardless of these personal feelings and the sense of disap-
pointment, it is necessary to deal with these problems and, more
important, with the patient’s anxieties, concerns, and possible
resentment. Most patients feel that something went wrong or
that something was not done properly³otherwise they would
have sailed through the operation as smoothly as their friend
did, on whom your partner, your colleague, or even you operated.
I usually explain the nature of the complication to the patient.
If I have any idea why it happened, I explain that and outline
our plan to take care of it. I usually tell the patient, ´I am sorry
this happened; it isn’t anything you did; it isn’t anything I did.
Despite our best efforts, we have a problem. It is not the first time
I have seen it, and we know how to take care of it.µ I then explain
exactly what has to be done and how long it will take.
In cases of postoperative hematoma in a facelift, I reoperate
usually with the patient under local anesthesia, but general anes-
thesia is available if needed, and I explain to the patient that this
will take care of the problem. It will not affect the results, but it
will leave more bruising than expected, and the affected side of
the face (if unilateral) will lag behind the other side in recovery.
Devastating complications, such as skin slough following a
facelift, exposed breast implants, and nipple or areola loss, require
a more prolonged plan for recovery. Fortunately, these complica-
tions are extremely rare and are often associated with predispos-
ing factors such as smoking. These patients require a great deal
of attention. :e naturally have an instinct to avoid unpleasant
situations and circumstances, but these are times when our
patients need us to be there for them. These patients must be seen
on an almost daily basis. If a strong bond already exists between
the patient and the surgeon before the complication develops, this
will have a positive influence on the outcome. However, if the sur-
geon’s relationship with the patient was already less than ideal,
these complications will serve to undermine the relationship
further and result in an unhappy situation for both the patient
and the physician. This is when patients become angry and seek
legal advice, especially if the complication adds an additional
financial burden to the patient. It may be tempting to abandon
such a patient and to blame him or her for the complication, but
it would be unwise. If you absolutely cannot continue with the
patient, have a partner or trusted colleague assume the care at
your expense.
:hen I have been able to explain the reason for the compli-
cation, I have found that patients have not only been surprised
by this explanation but also have appreciated my candor. This
communication has further improved our physician-patient rela-
tionship and the patient’s confidence in me. To do anything less
will confirm the impression that ´the medical profession covers
up errors.µ
There is no question that by offering to continue working
with the patient to correct a complication, you send a reassuring
message. I comfort patients by telling them that I have seen these
complications and know how to take care of them, and I will not
stop until we are both happy with the outcome.
1.12 7Ke 'iVVDWiVÀed 3DWienW
Dissatisfied patients come in two varieties³your own and those
of your colleagues. Despite our best efforts in preparing and
evaluating our own patients, screening them, and discussing
risks and complications and realistic expectations, we still have,
rarely, patients who are not satisfied with their outcomes. Even
though these patients may have an average or good result, they
are just not happy. This dissatisfaction may be the result of
inadequate or even poor communication between the surgeon
and patient or of patient expectations that were not met. Such
patients are extremely difficult to deal with and may never be
satisfied. They will exhaust you and test your patience and that of
everyone in your office. They also have access to the Internet and
the numerous websites that grade or evaluate doctors. They have
the freedom to say anything they want about you, your staff, and
their result. There are no checks and balances, and it is difficult,
if not impossible, to respond to these allegations or comments
once they have been posted. Although most of the time these
comments are posted anonymously, most surgeons have a good
idea who the patient may be but are bound by privacy rules from
commenting. The best way to deal with these patients is not to
operate on them, and with maturity and experience, one should
be able to identify them.
One of the most challenging problems in clinical practice is
dealing with a colleague’s dissatisfied patient. If the patient has
an identifiable problem that is correctable and the colleague
has referred the patient to you for that purpose, this represents
a relatively straightforward situation, since all three parties are
involved. However, most of the time the patient is self-referred
and would prefer that you not contact the original surgeon.
I evaluate these patients in the same manner that I evaluate any
patient. I then explain to them that the problem is correctable
and how I would do it. I also explain to them that I am flattered
and honored that they have chosen to consult with me, and I take
that as an indication of their confidence in me as a surgeon. If
the problem is a recognized and not uncommon complication or
sequela of the procedure, such as implant malposition or even lid
retraction, I explain that I have seen similar complications in my

14
I Fundamentals
own patients. If I am familiar with the other surgeon and believe
that he or she could just as easily correct the problem, I encourage
the patient to return to the original surgeon, who may do the
revision or correction at no charge or at a discount. I explain that
I would not charge my own patients for a similar revision. If the
patient does not wish to return to the other surgeon, he or she
will usually respond, ´He doesn’t think there is a problem,µ ´I can’t
communicate with him,µ or ´He says there is nothing else he can
do.µ I then tell the individual that I would have to charge my full
fee for the revision and that it may take more than one procedure. I
do ask all patients to have copies of their records forwarded to me,
and I ask their permission to communicate with the other surgeon.
If the patient does not grant permission, then it would be a breach
of his or her privacy to obtain the files, complicating the situation
and putting me in an awkward position with my colleagues. These
are extremely delicate situations, often involving litigation. It is
paramount that the patient’s best interests be considered first and
that everything possible be done to correct the problem, even at the
risk of affecting a collegial relationship. It is important to emphasize
that complications do not necessarily indicate a deviation from the
standard of care and to refrain from inflammatory comments such
as ´This is the worst I have ever seenµ or ´:ho did this to you"µ
:e are physicians and well-trained surgeons, highly skilled
in the procedures we perform. Communication skills, however,
were never part of our medical school or residency curriculum;
we were not taught bedside manner. Yet communication and
bedside manner are as important as our skills in the operating
room. Our patients expect more than good results; they like to be
listened to and cared for. They want a surgeon who is responsive
and who makes them feel valued and respected. Good results and
satisfied patients will do far more than any advertising program to
promote and grow a practice.
1.13 Concluding Thoughts
The practice of cosmetic medicine and aesthetic surgery is
satisfying and rewarding for the surgeon. I am excited that it
continues to evolve, and it is imperative that we adapt to these
changes so that we can provide the best for our patients. To our
patients, aesthetic treatments are not a necessity but rather are
the fulfillment of a personal goal; therefore, their experience
must be satisfying and rewarding as well. This is a partnership
that at its best works smoothly and effectively for all involved.
In this chapter I have shared my approach, but in truth it is our
approach³my partners and staff are all intimately involved in
making the experience for our patients a positive one. Time spent
with the patient by the surgeon and the staff is time well invested.
This is especially true today, when our patients have access to all
kinds of information on the Internet. Our goal is to establish a
long-term and trusting relationship with our patients. We nur-
ture an environment in which our patients can feel that they are
among friends when they visit us in our office. Patient satisfaction
is the best form of marketing available to us. Such patients are our
best source of referrals and will themselves return if the initial
experience was one worth repeating.
Clinical Caveats
• A well-informed patient is a happy patient.
• A well-motivated patient is a happy patient.
• Eliminate postoperative financial surprises, or at least warn
the patient about them.
• Listen to your patients.
• Learn to say “no.”
• Spend time with your patients.
• Respect the patient’s privacy.
• First impressions last.
• Your website is the face of your practice to the world.
• The Internet can be a friend or foe.
Suggested Reading
>1@ Bennett AE, ed. Communication between Doctors and Patients. London, U.:
Oxford University Press; 1976
>2@ Bennett G. Patients and Their Doctors: The Journey through Medical Care. London,
U.: Bailliqre-Tindall; 1979
>3@ Bird B. Talking with Patients, 2nd ed. Philadelphia, PA: -B Lippincott; 1973
>4@ Goldwyn RM. The consultant and the unfavorable result. In: Goldwyn RM, ed.
The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Boston, MA:
Little, Brown; 1972
>5@ Goldwyn RM. The dissatisfied patient. In: Goldwyn RM, ed. The Unfavorable
Result in Plastic Surgery: Avoidance and Treatment, 2nd ed. Boston, MA: Little,
Brown; 1984
>6@ Goldwyn RM. The Patient and the Plastic Surgeon. Boston, MA: Little, Brown;
1981
>7@ .uechel MC. Aesthetic Medicine: Growing Your Practice. St Louis, MO: 4uality
Medical Publishing; 2009
>8@ Lewis W. The Beauty Battle: The Insider’s Guide to Wrinkle Rescue and Cosmetic
Perfection from Head to Toe. Berkeley, CA: Laurel Glen Publishing; 2003
>9@ Lewis W. Plastic Makes Perfect. London, U.: Orion Books, 2007
>10@ Locke MB, 1ahai F. Managing the cosmetic patient. In: 1eligan MB, ed. Plastic
Surgery, vol. 2, 4th ed. London, U.: Elsevier; 2017:1–11
>11@ 1ahai F. ´:hat not to wearµ and other aspects of professionalism. Aesthet Surg J
2011;31(8):977–979 PubMed
>12@ 1ahai F. Evaluating the cosmetic patient on antidepressants. Aesthet Surg J
2014;34(2):326–327 PubMed

2 Psychological Considerations in Aesthetic Surgery
15
2 Psychological Considerations in Aesthetic Surgery
David B. Sarwer and Jacqueline C. Spitzer
Abstract
Aesthetic surgeons have long been interested in the psychosocial
functioning of their patients. Early work in the area suggested
that patients seeking aesthetic surgery were psychopathological.
However, contemporary research suggests that there are rela-
tively few differences between individuals who seek aesthetic
procedures and those who do not. Patients seeking aesthetic
procedures, however, present with increased body image dis-
satisfaction compared with those who do not elect to undergo
these procedures. This can be seen as more normative than
psychopathological in most patients.
1evertheless, there are several psychological considerations
of patients seeking cosmetic procedures that are relevant to
aesthetic surgeons. Because of this, a preoperative assessment of
psychosocial functioning should be conducted with a particular
focus on body dysmorphic disorder (BDD), eating disorders, and
depression. Psychosocial functioning also should be monitored
postoperatively, as patients can experience an exacerbation of
preoperative symptoms, sometimes with unfavorable results.
:hile research suggests that the majority of patients are satisfied
with the result of their cosmetic procedures, these psychosocial
considerations underscore the importance of the aesthetic sur-
geon being mindful of psychosocial functioning of their patients
throughout the continuum of care.
Keywords
psychosocial functioning, body dysmorphic disorder, eating
disorders, depression, body image, quality of life
2.1 Introduction
Tens of millions of individuals around the world undergo aes-
thetic procedures each year, from noninvasive procedures to
surgery, in an effort to improve their physical appearance. Many
aesthetic surgeons and mental health professionals long have
wondered why, from a psychological perspective, patients would
take on the expense and risks of an elective procedure to improve
their appearance. The early belief was that patients who sought
aesthetic treatments were dealing with significant underlying
mental health issues. Both empirical research and contemporary
clinical impression have largely debunked that belief, although
concerns about the psychological well-being of a minority of
patients remain. Providers and patients have also speculated on
the psychological changes that occur after treatment. The vast
majority of patients report being satisfied with the results of
their procedures, and many report meaningful changes in their
physical appearance, body image, and self-esteem. However,
some patients do appear to have untoward changes in psycho-
social functioning after surgery, underscoring the important
role of evaluating the psychosocial status of patients prior to an
aesthetic treatment.
This chapter provides an overview of the most relevant psycho-
logical considerations of patients who undergo aesthetic surgery.
The chapter begins with an overview of the hypothesized reasons
for the growth of aesthetic surgery. 1ext, a brief review of the
literature on psychological characteristics of aesthetic surgery
patients is provided. The psychiatric conditions of greatest rele-
vance to aesthetic surgeons³body dysmorphic disorder (BDD),
eating disorders, and depression³are discussed. The final section
of the chapter describes strategies for aesthetic surgeons to evalu-
ate the psychosocial functioning of patients.
2.2 Explanations for the Growth
of Aesthetic Surgery
There are a number of potential explanations for the worldwide
growth in aesthetic surgery and minimally invasive treatments.
A number of medical advances have made many treatments
safer and have decreased postoperative recovery times. Much of
the rapid growth of minimally invasive treatments is likely the
result of decreases in the cost of these procedures, as well as
the lower risk and shorter recovery times compared with tra-
ditional surgical procedures. Aesthetic procedures, unlike many
other forms of medicine, are tailor-made for direct-to-consumer
advertising. The latest advances in the field are a regular topic of
discussion in the mass media and coverage of the entertainment
industry. As a result, aesthetic procedures have become an
element of popular culture and are commonly viewed as a step
in the journey to the physical perfection routinely portrayed in
the mass media.
The mass media and entertainment industries also impact
thoughts and behaviors related to physical appearance in other
ways. From print magazines to websites, television shows to
movies, consumers are bombarded by images of physical beauty.
Some of the images are of persons who have been blessed with
youthful and symmetrical features that naturally signal attrac-
tiveness. Most, however, have been computer–enhanced. Studies
have repeatedly shown that exposure to these images of physical
beauty increases body image dissatisfaction that, as discussed in
detail in subsequent paragraphs, is believed to be the motivational
catalyst to aesthetic treatments.
Other sociocultural factors influence beliefs about physical
appearance and, likely, beliefs about aesthetic treatments. Parents
and peers impact our sense of our appearance starting in early
childhood and through modeling of behaviors signaling the
importance of physical appearance in social interactions. Early
experiences with romantic relationships also provide feedback to
an individual on how appearance is perceived by and responded
to by others. 1egative feedback about one’s appearance through
teasing or bullying is no longer seen as an innocuous rite of pas-
sage of adolescents; it can color beliefs about one’s appearance
and self-worth well into adulthood and, for many individuals, may
influence the decision to pursue an aesthetic procedure.

16
I Fundamentals
A large body of social psychological research developed over
the past 50 years has confirmed the importance of physical
appearance in daily life. This comprehensive body of research can
be summarized with two general statements:
1. Individuals who are judged to be more physically attractive are
assumed to have more positive and desirable personality char-
acteristics.
2. Individuals who are seen as more attractive receive preferential
treatment in a wide range of interpersonal interactions across
the lifespan.
:hether we like to admit it or not, the evidence that our
appearance impacts our lives is compelling.
A discussion of the role in physical appearance in the human
experience also has to include a consideration of Darwin’s theory of
natural selection, perhaps the earliest scientific acknowledgment
of the importance of physical appearance. According to the theory,
the goal of all species is survival through successful reproduction.
Identification of a mate who can optimize the results of reproduc-
tion is a central part of the process. To that end, specific physical
characteristics have evolved to signal reproductive capability to
others. These characteristics, particularly those that suggest the
potential for healthy reproduction, serve as the foundation for
what is considered attractive in another member of the species.
When applied to facial appearance, the characteristics of
youthfulness, symmetry, and averageness have been most com-
monly associated with facial attractiveness. The development of
adult facial features at puberty for both women and men signals
reproductive potential to others. These features also may suggest
reproductive health as expressions of normal levels of testoster-
one and estrogen. Clear skin, bright eyes, and lustrous hair draw
attention to the youthful face. :hile a youthful facial appearance
is considered attractive, an aging appearance typically is not.
Ratings of attractiveness of males and females typically decline
with age; the relationship is stronger for women than men.
Symmetry of facial features across the midline also is asso-
ciated with increased ratings of attractiveness. Evolutionary
theorists believe that the ability to develop symmetrical features
in an environment full of pathogens is conferred upon only the
healthiest of individuals. Similarly, averageness, with respect to
the size of individual facial characteristics, also is associated with
ratings of attractiveness. Composite faces made up of hundreds
or thousands of individual faces via computer technology (and,
therefore, believed to represent ´averageµ facial features) are
judged as more attractive than the individual faces that make
up the composite. The most beautiful of the combined faces for
women reflect a petite face with a smaller-than-average mouth
and jawline, full lips, and pronounced eyes and cheekbones. Many
surgical and minimally invasive treatments performed on the face
are undertaken to help an individual look more youthful and/or
enhance facial symmetry.
:ith these elements of evolutionary theory and social psycho-
logical research on appearance in mind, the popularity of aesthetic
treatments is not particularly surprising. :hile decades ago an
individual’s interest in improving his or her appearance may have
been seen as being symptomatic of excessive vanity, narcissism, or
other deep-seated psychopathology. Today, it also can be seen as
a more adaptive and potentially psychologically healthy behavior,
akin to other self-improvement strategies such as eating a healthy
diet and exercising regularly.
2.3 Psychological Characteristics
of Aesthetic Surgery Patients
A sizable body of research starting in the 1960s has investigated
the psychosocial characteristics of persons who present for
aesthetic surgery. The first studies in this area relied heavily on
clinical interviews of patients and described them as having high
rates of psychopathology, including mood and anxiety disorders
as well as personality disorders. All of these conditions were
believed to be associated with poor postoperative psychological
outcomes. Subsequent studies have included the use of standard-
ized psychometric measures rather than or in addition to clinical
interviews of prospective patients. These studies typically have
found less psychopathology. Unfortunately, both sets of studies
suffer from methodological problems that have made resolution
of these conflicting findings difficult.
In the past 20 years, advances in the use of psychometrically
validated measures have improved the quality of much of the
research done in this area. In particular, a number of psychomet-
rically sound patient-reported outcomes measures specifically
designed for plastic surgery patients have been developed. These
measures have focused on the assessment of quality of life,
self-esteem, and body image in patients before and after surgery.
Studies using these studies have largely found that patients typi-
cally report deficits in these areas prior to surgery.
2.4 Body Image
Over the past two decades, body image has been the psycho-
logical construct that has received the most research attention
in the aesthetic surgery literature. Dissatisfaction with one’s
facial appearance and body image is believed to be the primary
motivator for both surgical and minimally invasive treatments of
the face and body.
There are several definitions of the construct. Cash and
Pruzinsky defined body image as the perceptions, thoughts, and
feelings associated with one’s body and bodily experience. This
definition captured the multidimensional nature of body image,
including both the manner in which an individual objectively
appears to others, but also the manner in which a body moves in
time and space. These physical perceptions subsequently interact
with thoughts and feelings about the features of one’s appearance.
Unfortunately, this definition does not specifically highlight body
image behaviors, such as grooming habits and clothing selection,
as well as more profound behaviors, such as those seen with
aesthetic surgery. More recently, Cash and Smolak described body
image as the ´psychological experience of embodiment.µ This suc-
cinct description leaves the reader with a sense of the important
role that body image plays in quality of life, self-esteem, and the
overall human experience.
Much of our understanding of body image comes from a
cognitive–behavioral theoretical model, one of the dominant
theoretical models of psychology for the past several decades.
The model describes the perceptual, cognitive, affective, and
behavioral aspects of body image; it also accounts for historical
and proximal influences of the construct. Historical influences
include an individual’s physical characteristics, personality traits,
and interpersonal experiences. Proximal influences include
cognitive processing of appearance-specific information from the

2 Psychological Considerations in Aesthetic Surgery
17
environment that, along with more general cognitive processes,
lends ´meaningµ to situations and events.
These historical and proximal variables influence two funda-
mental body image dimensions. One is the degree of investment
in one’s appearance. Some individuals are highly invested in
their appearance (those who carefully groom themselves before
leaving the house); others are far less invested (those who are
comfortable going out in mismatched clothes or without groom-
ing). The second dimension is the degree of dissatisfaction. This
dissatisfaction is believed to fall on a continuum. Likely, very few
individuals are completely satisfied with their appearance on
a daily basis. Most individuals likely can identify features that
leave them dissatisfied. They may camouflage these features from
others (through makeup and/or clothing), but this dissatisfaction
does not routinely impact daily functioning. Others who are more
dissatisfied may exhibit more significant behavioral change in
response to their dissatisfaction. It is likely these individuals who
are most likely to seek and benefit from aesthetic procedures.
Finally, other individuals may exhibit a more extreme level of
body image dissatisfaction that may be representative of BDD or
other forms of formal psychopathology.
In general, there is consensus among thought leaders in the field
that individuals who seek and receive aesthetic procedures report
both heightened investment in their appearance as well as higher
levels of dissatisfaction. This relationship also has been supported
by research. Individuals who seek aesthetic procedures, both
surgical and nonsurgical, typically report heightened body image
dissatisfaction preoperatively. This dissatisfaction is typically
centered upon concern with the specific feature to be improved
with treatment. Thus, some degree of body image dissatisfaction
is believed to be a prerequisite to aesthetic surgery.
2.5 Formal Psychopathology
among Aesthetic Surgery
Patients
Given the number and diversity of individuals who seek aes-
thetic procedures, all of the psychiatric diagnoses can likely
be found within the patient population and a busy clinical
practice. However, three disorders³BDD, eating disorders, and
depression³likely warrant the greatest attention from aesthetic
surgeons and their team members.
2.5.1 Body Dysmorphic Disorder
BDD is a manifestation of extreme body image dissatisfaction. It
is defined by the American Psychiatric Association as a preoccu-
pation with a slight or imagined defect in appearance that leads
to substantial distress or impairment in social, occupational, or
other areas of functioning.
The disorder was not formally recognized until 1987.
1evertheless, the aesthetic surgery and dermatology literature
has included case reports of ´minimal deformity,µ ´insatiable,µ
and ´dermatological nondiseaseµ patients as early as the 1960s.
These individuals sought procedures to improve slight or imag-
ined defects and were often dissatisfied with their results. :hile
the incidence rate of BDD in the general population is believed to
be between 1 and 2, a number of studies conducted throughout
the world have found that 5 to 15 of cosmetic surgery patients
appear to have some form of the disorder. Although persons with
BDD typically report concerns with their skin, hair, and nose, any
body part can become a source of preoccupation.
Persons with BDD frequently seek cosmetic medical treatments
as a means of improving their perceived defects. More than
three-quarters of persons with BDD report a history of aesthetic
treatments. Unfortunately, most evidence to date suggests that
aesthetic procedures are inadvisable for patients with BDD.
Most patients report being dissatisfied with the outcome of
treatment, and two large studies have found that greater than
90 of persons with BDD report either no change or a worsening
in their symptoms following aesthetic treatments. A handful of
small studies, however, have found some degree of improvement
in symptoms in patients with mild to moderate forms of BDD.
Also of note, a number of studies have documented high rates of
suicidal ideation, suicide attempts, and self-harm behaviors (e.g.,
´do-it-yourselfµ surgery) among patients with BDD. There are
also reports of patients with BDD who have threatened to sue or
physically harm aesthetic treatment providers. In light of these
issues, there is consensus that aesthetic treatments likely should
be contraindicated for persons with BDD.
2.5.2 Eating Disorders
Extreme body image dissatisfaction is a symptom of both
anorexia and bulimia nervosa. :omen (and men) with both
conditions may mistakenly believe an aesthetic treatment will
improve their intense dissatisfaction with their bodies. Eating
disorders may be a particular concern for individuals who
seek body contouring procedures, including liposuction and
abdominoplasty as well as breast augmentation. Patients may
mistakenly believe that these procedures can reshape their
bodies in a way that restrictive eating and/or maladaptive com-
pensatory behaviors cannot. :omen who present for cosmetic
breast augmentation are frequently below average weight and
report greater exercise compared to physically similar women
not seeking breast augmentation, both of which also may be
suggestive of eating psychopathology. Unfortunately, the study
of the relationship between eating disorders and other cosmetic
procedures has been limited to small case series.
2.5.3 Depression and Suicide
The presence of major depression or other mood disorders also
warrants particular attention. Population estimates suggest that
approximately 10 of adults are suffering with depression at any
point in time and approximately 20 are using an antidepressant
medication. Studies have suggested that the rate of usage among
aesthetic surgery patients is higher and perhaps double that of
the general population. :omen seeking breast augmentation
also have been found to report a higher rate of outpatient psy-
chotherapy and psychiatric hospitalizations.
Of greater relevance, seven epidemiological studies have found
an association between cosmetic breast implants and suicide.
Across these studies, the rate of completed suicides was two to
three times higher among implant recipients than estimated rates
in the general population. Explanations of this relationship have
largely focused on the preoperative psychosocial status and func-
tioning of the women. Women who undergo breast augmentation

18
I Fundamentals
have been shown to have a number of distinguishing demographic
characteristics. They report more lifetime sexual partners, a
greater use of oral contraceptives, and a history of terminated
pregnancies. They also are more frequent users of alcohol and
tobacco. Many of these characteristics are, in and of themselves,
risk factors for suicide.
The most likely explanation of the relationship between cos-
metic breast implants and suicide appears to be the presence
of pre-existing psychopathology prior to surgery. In one of the
epidemiological studies, women who underwent cosmetic breast
augmentation had a higher rate of previous psychiatric hospi-
talizations compared with women who received other cosmetic
procedures, as well as women who underwent breast reduction.
A history of psychiatric hospitalizations is one of the strongest
predictors of suicide among persons in the general population.
2.6 Psychosocial Status Following
Aesthetic Surgery
1umerous studies have found that 80 to 90 of patients report
being satisfied with the results of an aesthetic procedure. Other
studies also have found statistically significant improvements
in body image within the first 2 years of an aesthetic surgical
procedure. In a recent systematic review, aesthetic patients also
reported improvements in quality of life and self-esteem follow-
ing both surgical and nonsurgical aesthetic procedures.
An issue that has received surprisingly little attention is the
relationship between postoperative complications and psycho-
social outcomes following aesthetic procedures. Intuitively, post-
operative satisfaction and the psychological benefits associated
with improvements in appearance may be negatively impacted
by the occurrence of a postoperative complication. At least one
study found that breast augmentation patients who experienced
postoperative complications reported less favorable changes in
body image in the first 2 years following surgery. Unfortunately,
little else is known about these relationships.
2.7 Assessment of Psychosocial
Functioning by the Aesthetic
Surgeon
Given these research findings, aesthetic surgeons are encouraged
to conduct a basic assessment of the psychosocial functioning
and status of new patients. Aesthetic surgeons, like all medical
professionals, should assess and screen for the presence of
psychopathology as part of a taking of a medical history and
completion of physical examination. The assessment should
focus on three main areas: (1) motivations and expectations, (2)
appearance and body image concerns, and (3) psychiatric status
and history.
2.7.1 Motivations and Expectations
Patients present for aesthetic procedures with a variety of moti-
vations and expectations regarding the impact of surgery on
their lives. Some may be expressed to the surgeon or treatment
team during the initial consultation; others may be unspoken.
:hile both patients (and surgeons) may struggle to articulate or
identify specific motivations for surgery, patients with internal
motivations (e.g., desire to improve one’s self-confidence) rather
than external motivations (e.g., undergoing surgery in order to
receive a promotion) are thought to be more likely to have their
postoperative expectations met.
In assessing patients’ motivations for surgery, the surgeon may
want to begin by asking, ´:hen did you first think about changing
your appearance"µ Similarly, it may be instructive to ask, ´:hat
other things have you done to improve your appearance"µ In addi-
tion to providing important clinical information, these questions
also may reveal the presence of some obsessive or delusional
thinking, as well as bizarre or compulsive behaviors, related to
physical appearance.
Patients should be asked how romantic partners, family
members, and close friends feel about the decision to change a
physical feature. :hile these individuals likely influence patients’
decision-making process, their role may not be as great as
intuitively thought. Breast augmentation patients reported that
their decision to seek surgery was influenced more by their own
feelings about their appearance than by the thoughts of their
romantic partners. 1evertheless, patients who seek treatment
specifically to please a current partner, or to attract a new one,
are thought to be less likely to be satisfied with their postopera-
tive outcomes. Thus, the surgeon should inquire about patients’
general expectations about how the change in appearance, which
may be rather subtle and potentially unnoticed by others, will
influence their lives.
:hile there is some evidence to suggest that patients are seen
as more attractive or thought to be younger after an aesthetic
treatment, there is no current evidence suggesting that cosmetic
procedures directly impact interpersonal relationships. Therefore,
patients should be reminded that it is impossible to predict how
others will respond to their changed appearance. Some patients
may find that few people notice the change in their appearance,
while others may have the experience that everyone seems
to notice them. :hile some patients may find this attention
pleasurable, others may find it uncomfortable. To assess this
issue, patients should be asked how they anticipate their lives
will be different following surgery. The experience of unmet
postoperative expectations is another possible explanation of the
relationship between cosmetic breast augmentation and suicide.
Some women may present for breast augmentation surgery with
unrealistic expectations about the effect that the procedure will
have on their romantic relationships or daily functioning. :hen
these expectations are not met, they may become despondent,
depressed, and potentially suicidal.
2.7.2 Body Image Dissatisfaction and
Body Dysmorphic Disorder
The aesthetic surgeon also should assess the degree of body
image dissatisfaction and potential presence of BDD. Patients
should be able to articulate specific concerns about their appear-
ance that are readily visible to the treating surgeon, as patients
who are markedly distressed about slight defects that are not
easily apparent may be suffering from BDD. As the judgment of
an appearance defect as ´slight or imaginedµ is highly subjective,
the nature of the appearance defect may be difficult to assess.

2 Psychological Considerations in Aesthetic Surgery
19
:hat a lay person regards as a slight defect, well within the range
of normal, may, to the trained aesthetic surgeon, be a defect that
is observable and easily correctable. As a result, the degrees of
emotional distress and impairment, rather than the specific
nature of the defect, may be more accurate indicators of BDD.
The degree and psychosocial consequences of the patient’s
body image dissatisfaction should also be assessed. Asking about
the amount of time spent thinking about a feature or the activ-
ities missed or avoided may indicate the degree of distress and
impairment a person is experiencing and may help determine the
presence of BDD.
2.8 Psychiatric Status and History
An assessment of the patient’s psychiatric history and current
status should be included in the consultation with a new patient.
:ith the exception of BDD, there is limited data on the preva-
lence of psychiatric diagnoses among persons who undergo cos-
metic procedures. The presence of a specific diagnosis, however,
may not be an absolute contraindication for cosmetic surgery.
In the absence of sound data on the relationship between psy-
chopathology and surgical outcome, appropriateness for surgery
should be assessed on a case-by-case basis.
Aesthetic surgeons (or their delegates) should ask specific
questions about current and past diagnoses and treatments (both
outpatient and inpatient). Although this information is frequently
reported on standard medical history forms, review during the
initial consultation allows for observation of the patient’s behavior,
demeanor, and ability to interact with office staff. Unfortunately,
many surgeons likely skip this psychological screening portion of
the assessment and, as a result, likely fail to identify patients who
may exhibit symptoms of relevant psychopathology.
Patients who display symptoms of psychopathology during
their initial consultation with the aesthetic surgeon, as well as
those with a history of psychopathology, may benefit from a
referral for additional assessment by a mental health professional.
Many of the early descriptions of cosmetic surgery patients are
complete with elaborate interpretations of the role of unconscious
conflicts and poor parental relationships in the decision to seek
surgery. There is no evidence, however, to suggest that such
interpretations are necessarily valid or useful in determining
patients’ appropriateness for surgery. Thus, a detailed assessment
of patients’ parental relationships and decades-old historical
experiences is unlikely to provide useful information to the refer-
ring surgeon in determining appropriateness for surgery. Rather, a
more straightforward evaluation of patients’ current functioning,
as found in the more general cognitive-behavioral assessment, is
recommended.
A trusted mental health professional can be a valuable con-
sultant to an aesthetic surgery practice. This mental health pro-
fessional should have a good understanding of the psychological
aspects of aesthetic medicine, as well as knowledge of disorders
with a body image component, such as BDD and eating disorders.
In most cases, the mental health professional will be called upon
to assess a patient’s psychological appropriateness for a procedure
at a given point in time. The mental health professional also may
be asked to join in the care of a patient postoperatively. This is
most likely to occur in situations where the patient is dissatisfied
with an objectively successful outcome or when the patient
experiences a significant postoperative complication. Aesthetic
surgery patients may react to a referral to a mental health profes-
sional with anger and defensiveness, believing that they will feel
better only if they look better, and therefore may refuse to go to
the consultation. To increase the likelihood that the patient will
accept the referral, it should be treated like a referral to any other
health professional. The patient should be informed of the specific
areas of concern and the reason for the referral, and this informa-
tion also should be shared with the mental health professional.
2.9 Concluding Thoughts
Aesthetic surgeons have long been interested in the psychosocial
functioning of their patients. The earliest work in this area, before
the tremendous growth of the specialty, generally suggested that
patients were highly psychopathological. As aesthetic surgical
and minimally invasive treatments have become more common,
this perception has changed. Individuals who present for pro-
cedures are not seen with the same degree of suspiciousness as
before. Furthermore, most of the more contemporary research
has suggested that there are relatively few differences between
individuals who seek aesthetic procedures and those who do
not. The most consistent difference seems to be increased body
image dissatisfaction, which is believed to be the motivation
catalyst for an aesthetic procedure.
Encouragingly, many patients report improvements in their body
image following a cosmetic treatment. However, a small yet signifi-
cant percentage of patients appear to suffer from BDD. Others likely
suffer with eating disorders or depression. All three conditions
should be assessed preoperatively. Psychosocial functioning also
should be monitored postoperatively, as patients can experience
an exacerbation of these symptoms, sometimes with dramatically
unfavorable results, such as threats of legal action, physical harm,
and suicidal behavior. These outcomes underscore the importance
of the aesthetic surgeon’s being mindful of psychosocial status and
functioning throughout the continuum of care of the patient.
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3 Photographic Essentials in Aesthetic Surgery
21
3 Photographic Essentials in Aesthetic Surgery
Walter C. Lin, William Y. Hoffman, and Farzad R. Nahai
Abstract
Understanding of fundamental concepts and basic photographic
knowledge are required for accurate and reproducible medical
photography. This chapter discusses terminology and key ele-
ments with emphasis on the clinical setting, including the inter-
play between shutter speed, aperture, and ISO speed in obtaining
proper exposure, as well as appropriate selection of focal length,
acceptable lighting, metering adjustment, and control of depth
of field. Photographic standards are reviewed for various regions
of interest. Also discussed are considerations regarding digital
photography, including key differences between smartphones,
point-and-shoot, and single-lens reflex (SLR) cameras and the
impact of varying sensor size, file format, resolution, dynamic
range, and file storage. Medicolegal aspects of Health Insurance
Portability and Accountability Act (HIPAA) compliance and pri-
vacy now play critical roles in every surgeon’s practice.
Purposeful selection of focal length, exposure, and lighting
permits capture of reproducible, standardized clinical photog-
raphy. Application of advanced topics enable the surgeon to
capture studio-quality images without the need for a dedicated
photographer.
Keywords
photography, photographic standards, digital camera, SLR,
lenses, smartphone, point-and-shoot, flash, postprocessing,
HIPAA
3.1 Introduction
Photography plays a critical yet understated role in the practice of
plastic surgeons. Perhaps most important is the ability to create
standardized and reproducible photographs of the patient over
time, such that the only aspect of the photograph that changes
is the patient and nothing else. The underlying principles lay
groundwork in clinical planning, medicolegal documentation,
and patient communication. Comprehension of the underlying
fundamental concepts enables meaningful application of pho-
tography in educational and commercial marketing settings.
Although most principles of photography have remained
unchanged over the previous decades, new considerations have
arisen because of technological advances in digital photography.
The last decade has experienced exponential growth in the
quality and accessibility of camera equipment, photo processing
software, and image sharing that requires new considerations.
Image quality from mobile phones and devices nearly rivals
professional equipment from the last decade. Some modern
professional equipment is no longer prohibitively expensive and
is readily available even for surgical trainees. Virtually unlimited
digital storage space allows documentation of every aspect of
care³by both the physician and the patient.
:hereas photos were once taken sparingly due to the prohib-
itive costs of film and film development, photos are now taken
easily and often. 4uality photography requires careful, thoughtful
setup; however, software now enables correction of minor flaws in
lighting, exposure, and other elements of composition. Traditional
portfolios were once collected in elegant leather-bound binders,
but high-speed Internet now enables instantaneous sharing
globally, opening unprecedented possibilities for media use in
education and publication.
Because of this digital evolution, it is crucial to understand
older fundamental principles in addition to newer concepts so as
to make full use of photography in one’s practice. Skilled photog-
raphy is essential in the practice of any plastic surgeon, no matter
whether photography is provided by a third-party photographer
or by surgeons themselves. This chapter describes the essential
concepts underlying photography, lighting, and image processing,
as well as digital considerations³all important elements for
creating photos suitable for documentation as well as publication.
3.2 Background
Whether referring to a camera phone, point-and-shoot, or
single-lens reflex (SLR) camera, certain concepts and consider-
ations remain universal. Conceptually, photographs are collections
of light photons reflected from the subject, which are collected
and focused through a lens and finally activate a film negative or
a digital sensor that records them. The combination of the lenses,
aperture, and shutter control the characteristic way light contacts
the sensor, determining how the subject and background are
portrayed.
The following sections detail key elements that characterize
a photograph. With understanding and practice, each element
can be altered to achieve desired and consistent results, such as
a blurred background and foreground that isolate the subject in
portrait photography, or tack-sharp photographs to highlight
clinical findings.
3.3 Basic Elements of Exposure
3.3.1 Focal Length, Shutter Speed,
Aperture, ISO Speed
Focal Length
Focal length is the distance from the optical center of the lens
to the focal point on the image sensor at which the image is
properly focused. The ratio of the sensor size to the lens focal
length determines the field of view. Longer focal lengths magnify
the image and create a narrow field of view, as experienced with
telescopes or telephoto lenses, while shorter focal lengths allow
a wide viewing angle at the expense of distortion, as with front
door peepholes or fisheye lenses.

22
I Fundamentals
Because the ratio of the sensor size to the focal length deter-
mines field of the view, standard convention expresses focal
length in terms of 35-mm film/sensor equivalent. The field of
view of the human eye is approximated by a 40- to 50-mm lens.
Clinical photographs are best taken using portrait lenses in the
85-mm to 135-mm range.
Selecting a Lens: Zoom versus Prime Lenses
=oom lenses provide versatility and convenience over a con-
tinuous range of focal lengths. However, their complex design
requires increased weight, size, and cost as well as compromises
in optical performance and aperture size. =oom lenses typically
demonstrate their worst image quality at the extremes of per-
formance: at the longest or shortest focal lengths, and with the
largest and smallest apertures.
In contrast, prime lenses provide only one fixed focal length.
The simpler design requires fewer parts, which have all been opti-
mized solely for one focal length. Overall, the result is a lighter,
smaller lens with sharper images than can be obtained with zoom
lenses at the same focal length. The lack of variable focal lengths
is easily overcome by simply walking toward or away from the
subject or changing lenses.
The choice between zoom and prime lenses is a personal pref-
erence. If nearly all photos are taken at a specific focal length, then
better results would be obtained by switching to a prime lens.
Pitfalls: Optical Distortion and
Perspective Distortion
Clinical photographs commonly suffer from distortion associ-
ated with wide-angle lenses (shorter than 40 mm) in the form of
optical distortion and perspective distortion.
Unwanted distortion is minimized in clinical photography
by selecting medium telephoto lenses (85 mm to 135 mm) and
stepping farther from the subject. If space is limited, the distance
between the subject and photographer must be maximized, with
the longest focal length possible.
Also known as ´lens distortionµ or ´barrel distortion,µ optical
distortion consists of the curved appearance of straight lines
because our total field of view, including all the objects that we can
see around us, is a sphere, but the camera projects that view onto
a flat surface. Although all lenses have some amount of distortion,
the effect is more prominent in wide-angle lenses, which include
a larger portion of the total field of view (Fig. 3.1), just as a map
of a small part of the earth, such as a city neighborhood, shows
straight lines as straight, but a map of the whole earth is always
distorted in some way. Again, selection of a medium telephoto
lens minimizes the risk of distortion of clinical photographs.
In contrast to optical distortion, perspective distortion can be
avoided. Perspective distortion refers to the bulging appearance of
the subject when the subject is too close to the camera. This exag-
gerates the differences in distance between different parts of the
subject; closer parts look much larger than more remote parts. In
Fig. 3.2, the same magnification is simulated in both images, but
Fig. 3.2b was taken at a much closer distance than Fig. 3.2a. The
model’s face is drastically different between the two images.
Distortion should be minimized by using longer focal lengths
(medium telephoto, portrait, or telephoto) and by placing the
subject farther from the camera. Longer focal lengths have the
Fig. 3.1 Optical distortion is most apparent when viewing (a) a large
grid of parallel lines through a wide-angle lens, where (b) the lines
appear to be curved.
a
b
Fig. 3.2 Selection of the proper focal length minimizes perspective
distortion. (a) Frontal view taken using a 90-mm lens at 1 meter
distance provides no significant distortion. (b) The same magnification
with a 50-mm lens requires a shorter working distance, which distorts
facial features (the subject’s nose and lips are proportionally much
closer to the camera than her ears and neck are). The flash angle is also
exaggerated and casts harsher shadows.
a
b