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

SECTION I INTRODUCTION
16
or imagined defects and were often dissatisfied with their
results postoperatively.4 Although 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.4 Although persons with BDD
typically report concerns with their skin, hair, and nose, any
body part can become a source of preoccupation.4,37,38
Persons with BDD commonly seek cosmetic medical
treatments as a means of improving their perceived de­
fects.37,39–41 In a survey of 289 patients, Phillips and col­
leagues40 found that 76.4% of patients with BDD sought cos­
metic or dermatologic treatment, with other studies finding
similar results.39,42 A more recent survey of 234 patients vis­
iting a facial plastic and reconstructive surgery clinic found
that 13.1% of patients undergoing cosmetic surgery and 1.8%
of patients undergoing reconstructive surgery who visited
the clinic over a 4-month span had BDD.37 The most com­
mon procedures sought by patients with BDD are surgeries
like rhinoplasty, breast augmentation, and liposuction, as
well as minimally invasive procedures such as collagen injec­
tions, microdermabrasion, and dental repairs.39–41
In light of cosmetic surgery’s inherent objective to en­
hance physical features that to some may be considered
perfectly normal, it is often difficult to distinguish patients
with BBD from other patients who seek cosmetic surgery. As
noted previously, many cosmetic surgery patients present
with body image dissatisfaction preoperatively. Thus deter­
mining the degree of a patient’s dissatisfaction with body
image, and the subsequent distress caused, is essential in
discriminating between patients with and without BDD.4
For some patients the degree of distress can be so severe
that it causes them to revert to previous habits of self-injury.
In a survey of 25 patients with BDD who had under­
gone 46 cosmetic procedures, researchers found that 9 pa­
tients were so distressed by their appearance that they per­
formed “do-it-yourself” procedures in an attempt to enhance
their appearance and rid themselves of their perceived de­
formity.43 Examples of these extreme measures included a
man who was so obsessed with his skin that he used sand­
paper to remove scars and smooth his skin, and a woman
who used a knife to cut out fat from her thighs.43 Although
these extreme cases of self-performed cosmetic procedures
are rare, it is likely that other patients use less severe, but
equally unsuccessful, measures to improve their appearance.
In contrast to most cosmetic surgery patients, individ­
uals with BDD are typically dissatisfied with the outcome
of such treatments.42 Although a handful of studies suggest
cosmetic surgery can result in positive outcomes for patients
with BDD, these findings are limited, because the studies fo­
cused on specific procedures and patients with mild to mod­
erate BDD symptoms.38,44 Aside from the aforementioned
few, and methodologically limited, studies, most evidence to
date suggests that cosmetic procedures and treatments are
inadvisable for patients with BDD.4 Two retrospective stud­
ample, 91% of adolescents who had undergone bariatric sur­
gery reported feeling unattractive because of their excess
skin.25
Nevertheless, though some degree of body image dissat­
isfaction is believed to be a prerequisite to cosmetic surgery,
these feelings may also be representative of several forms of
formal, severe psychopathology.
Formal Psychopathology
As mentioned previously, preoperative psychopathology
among patients is a primary focus of cosmetic surgery re­
search. The first studies of this issue, conducted decades
ago, relied heavily on clinical interviews of cosmetic sur­
gery candidates and described them as having high rates
of psychopathology, including mood and anxiety disorders,
as well as personality disorders.26–29 All of these condi­
tions were believed to be associated with poor postopera­
tive psychological outcomes. More recently, studies have
included the use of standardized psychometric measures
rather than or in addition to clinical interviews of pro­
spective patients; these studies typically have found less
psychopathology.23,24,30,31 Both sets of studies suffer from
methodological problems that have made interpretation
of these conflicting findings difficult.4,5,20,32 Thus the rate
of psychopathology among cosmetic surgery patients re­
mains poorly understood and, perhaps more importantly,
the relationship between preoperative psychopathology
and postoperative outcomes is largely unknown.
Given the number and diversity of individuals who now
seek cosmetic surgery, all of the psychiatric diagnoses can
likely be found within the patient population. However,
three disorders in particular—body dysmorphic disorder,
eating disorders, and depression—warrant the greatest at­
tention from plastic surgeons and the mental health profes­
sionals asked to consult on a patient’s psychological appro­
priateness for surgery.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is defined as a preoccupa­
tion with a slight or imagined defect in appearance that
leads to substantial distress or impairment in social, occu­
pational, or other areas of functioning.33 The disorder of­
ten develops in adolescence, as individuals become more
aware of and concerned with their physical appearance and
attractiveness.34
Although not introduced into the Diagnostic and Statisti­
cal Manual of Mental Disorders (DSM) until the third edition
in 1987, cosmetic surgery literature included descriptions of
“minimal deformity” and “insatiable” patients as early as the
1960s, and dermatology literature described case reports
of patients with “dysmorphophobia” and “dermatological
nondisease” in the 1980s.35,36 Like contemporary BDD pa­
tients, these individuals sought procedures to improve slight

17
Chapter 3 Psychological Aspects of Cosmetic Surgery and Minimally Invasive Treatments
suggested that approximately 20% of persons presenting for
cosmetic surgery are engaged in mental health treatment,
most typically the use of an antidepressant or other psychi­
atric medication.53 Compared with other cosmetic surgery
patients and women from the general population, women
considering breast augmentation or those with breast im­
plants have been found to report a higher rate of outpatient
psychotherapy, psychopharmacologic treatments, and psy­
chiatric hospitalizations.24,53,54 Although these studies sug­
gest that the rate of psychopathology may be higher among
patients with breast implants, the investigations provided
no information on the specific psychiatric diagnoses of
these women.
Of even greater concern is the association between cos­
metic surgery and suicide. Seven epidemiologic studies
investigating the relationship between silicone gel–filled
breast implants and all-cause mortality have found an as­
sociation between cosmetic breast implants and suicide.55
For example, using medical records from 13,488 cosmetic
breast implant patients and 3,936 other cosmetic surgery
patients, cosmetic breast implant patients experienced a
higher mortality rate than the other cosmetic surgery pro­
cedure patients (relative risk 1.27; 95% confidence interval
[CI] 1.0–1.6), noting higher numbers of brain cancer (N = 13;
standardized mortality ratio [SMR] 2.25), respiratory cancer
(N = 32; SMR 3.03), and suicide (N = 19; SMR 4.24) deaths.56
Overall, results from these six studies indicate that the sui­
cide rate among cosmetic breast implant patients is two to
three times higher than estimated rates in the general popu­
lation, with a total 126 patients committing suicide postop­
eratively across the studies.55
Although specific reasons for this phenomenon have not
been widely studied, explanations of the relationship be­
tween breast implants and suicide have primarily focused
on the preoperative psychosocial status and functioning of
the women.2,55,57,58 Women who undergo breast augmenta­
tion have been shown to have a number of distinguishing
demographic characteristics. Not only are they more likely
to report more lifetime sexual partners and a greater use of
oral contraceptives, but they also tend to be younger at the
time of their first pregnancy and have a history of termi­
nated pregnancies. In addition, these women are more likely
to use alcohol and tobacco and, as noted previously, have a
below-average body weight. Many of these characteristics
alone are risk factors for suicide.
At present, the most intuitively consistent explanation
of the relationship between cosmetic breast implants and
suicide appears to be the presence of preexisting psycho­
pathology before implantation. However, only one of the
epidemiologic studies provided any information on the
psychiatric history of the women studied; it documented a
higher rate of previous psychiatric hospitalizations among
women with breast implants, compared with both women
who received other cosmetic procedures and women who
underwent breast reduction.54 Among women in the general
population, a history of psychiatric hospitalizations is one of
the strongest predictors of suicide.59–61 Unfortunately, Jacob­
ies have found that greater than 90% of persons with BDD re­
port either no change or a worsening in their BDD symptoms
after cosmetic treatments.39,45 Similarly, a prospective study
of 166 cosmetic rhinoplasty patients found that BDD symp­
tom scores were inversely related to postoperative satisfac­
tion and quality of life 3 and 12 months after surgery.46 Of
even greater concern, studies have documented high rates of
suicidal ideation, suicide attempts, and self-harm behaviors
(e.g., “do-it-yourself” surgery) among patients with BDD.43,47
There are also reports of patients with BDD who have
threatened to sue or physically harm their treatment provid­
ers.48,49 For example, in 2000 the New York Supreme Court,
Appellate Division, saw a malpractice case in which a cos­
metic surgery patient suffering from BBD sued her surgeon
for malpractice, claiming her BDD symptomology prevented
her from providing informed consent, her surgeon failed to
inform her of other treatment options, and that the surgeon
was negligent in his performance of the surgery.50 In a recent
survey of 260 American Society for Dermatologic Surgery
(ASDS) members,49 30 surgeons reported being threatened
by a patient with BDD, 24 reported a legal threat, and 6 re­
ported a physical threat. In light of these issues, a growing
consensus has developed that cosmetic medical treatments
should be contraindicated for persons with BDD.4,10,20,51,52
Encouragingly, many surgeons refuse to perform procedures
on patients who they believe to have BDD.39,40,48 Although
screening methods for BDD vary, several groups have sug­
gested the use of both the Body Dysmorphic Disorder Ques­
tionnaire (BDDQ) and direct questions about BDD symp­
toms.4,37
Eating Disorders
Given the disproportionate amount of concern that pa­
tients with eating disorders place on their appearance,
these disorders may be more common among those who
seek cosmetic surgery. Patients with eating disorders may
erroneously believe that surgery will improve their in­
tense dissatisfaction with their bodies. Eating disorders
may be a particular concern for women (and men) who
seek body contouring procedures, including liposuction,
abdominoplasty, and even breast augmentation. Patients
may mistakenly believe that these procedures can reshape
their bodies in a way that restrictive eating or maladaptive
compensatory behaviors cannot. Women who present for
cosmetic breast augmentation are typically below average
weight and report greater exercise compared with physi­
cally similar women not seeking breast augmentation, both
of which also may be suggestive of eating psychopathol­
ogy.20,22–24,27–29 Unfortunately, the study of the relationship
between eating disorders and other cosmetic procedures
has been limited to small case series.
Depression
The presence of major depression or other mood disorders
also warrants particular attention. At least one study has

SECTION I INTRODUCTION
18
1. Motivations and expectations
2. Appearance and body image concerns
3. Psychiatric status and history
Assessing presurgery motivations can be as simple as ask­
ing patients why they want the procedure. Typically inter­
nally motivated patients (e.g., those who seek to improve
their self-esteem or body image) fare better than externally
motivated individuals (e.g., those who hope to save their
marriage or get a coveted promotion), so understanding pa­
tients’ underlying motivations can help frame further dis­
cussion about the procedure. Similarly, knowing whether
patients’ postoperative expectations are surgical, psycho­
logical, or social in nature provides surgeons the opportu­
nity to correct any misconceptions or unrealistic expecta­
tions regarding the procedure’s likely outcome. Research
has demonstrated that patients who are internally moti­
vated and have realistic expectations tend to fare better
than externally motivated patients. Although studies sug­
gest patients are regarded as more attractive after their cos­
metic procedure, no current evidence suggests that social
relationships will improve after surgery. Ensuring patients
understand what is and is not likely to change postopera­
tively can help prevent unmet expectations and grievances.
Evaluating patients’ body image concerns is also an impor­
tant component of the psychological assessment, because
patients who suffer from BDD are less likely to experience
improvements in their symptoms. Questions that reveal the
degree to which patients are dissatisfied with their bodies
and the extent to which these negative feelings affect their
daily life can unveil potential BDD symptomatology.
Surgeons also should gather information regarding a
patients’ psychiatric history and status. Although this infor­
mation is reported on most standard medical history forms,
probing deeper with a one-on-one interview allows clini­
cians to better observe the patient’s behavior, demeanor, and
ability to interact with office staff. Studies suggest that 19%
of cosmetic surgery patients report a mental health history,
which often includes a variety of mood and eating disor­
ders.53 Surgeons should take note of these issues and refer
patients of concern to mental health professionals before
surgery.
Unfortunately, most plastic surgeons (or their delegates)
likely skip this psychological screening portion of the assess­
ment and, as a result, fail to identify patients who may ex­
hibit symptoms of psychopathology. For example, a survey
of 260 ASDS members found that although three quarters of
surgeons reported asking patients about their motivations
(76.7%) and expectations (76.4%) for surgery, less than two
thirds (60%) asked about mental health history during the
physical exam, and only one fifth consulted with a mental
health provider regarding a patient’s mental health status.49
Encouragingly, most patients interested in cosmetic
medical treatments are believed to be psychologically ap­
propriate for such treatments.2,3,69 These patients typically
have specific appearance concerns, internal motivations, and
realistic postoperative expectations. Thus most patients do
sen and colleagues54 did not report information on diagno­
sis, history of illness, or other psychiatric treatments for the
women in their sample.
Psychosocial Status after
Cosmetic Surgery
Despite the aforementioned concerns regarding the psy­
chosocial status of some patients, most cosmetic surgery
patients report satisfaction with their postoperative result
in the first few years after surgery.16,31,62,63 Studies sug­
gest that most women report improvements in body im­
age within the first 2 years after cosmetic surgery.31,64–66
In a systematic review of 16 articles, Imadojemu and col­
leagues67 found that cosmetic procedures can improve
numerous psychosocial domains. Specifically, the articles
reviewed reported improvements in quality of life, body
image, and self-esteem among a variety of different cos­
metic procedures including Botox injections, laser resur­
facing, rhinoplasty, rhytidectomy, and blepharoplasty.67
Despite these encouraging findings, it is important to note
that this evidence is limited, because many of these studies
contained methodologic issues that call into question the
validity of the findings.67
An issue that has received surprisingly little attention is
the relationship between postoperative complications and
psychosocial outcomes after surgery. Intuitively, postopera­
tive satisfaction and the psychological benefits associated
with cosmetic surgery may be negatively impacted by the
occurrence of a postoperative complication.8 At least one
study found that breast augmentation patients who experi­
enced postoperative complications reported less favorable
changes in body image in the first 2 years after surgery.65
Unfortunately little else is known about these relationships.
Preoperative Psychological
Assessment of Cosmetic Surgery
Patients
Despite these mental health issues, cosmetic surgeons
typically do not require all patients to undergo a mental
health evaluation before cosmetic surgery. In the competi­
tive marketplace of cosmetic medicine, such a policy would
likely drive patients to other practices almost immediately.
More importantly, given the lack of current evidence sug­
gesting a relationship between preoperative psychosocial
status and postoperative outcomes, recommendations for
such routine evaluations is not warranted. Rather, cosmetic
surgeons, like all medical professionals, should assess and
screen for the presence of psychopathology as part of a tak­
ing of a medical history and completion of physical exami­
nation.
When screening for psychopathology, surgeons should
focus on three main things68:

19
Chapter 3 Psychological Aspects of Cosmetic Surgery and Minimally Invasive Treatments
sence of sound data on the relationship between psychopa­
thology and surgical outcome, appropriateness for surgery
should be made on a case-by-case basis.
As discussed previously, approximately 20% of patients
who seek cosmetic medical treatment report using a psy­
chiatric medication at the time of treatment.53 Patients who
receive these medications from a primary care physician of­
ten do not experience complete relief from their symptoms.
Therefore a psychopharmacologic evaluation should be con­
sidered if symptoms do not appear to be well controlled. If
patients are in treatment with a mental health professional,
the surgeon should contact this professional and, if neces­
sary, discuss their appropriateness for cosmetic treatment.
Physical Appearance and Body Image
Potential patients should be able to articulate specific con­
cerns about their appearance that are readily visible to the
treating surgeon; patients who are markedly distressed
about slight defects that are not easily apparent may have
BDD. Because the judgment of an appearance defect as
“slight or imagined” is highly subjective, the nature of the
appearance defect may be difficult to assess. What a lay
person regards as a slight defect, well within the range of
normal, may, to the trained cosmetic surgeon, be a defect
that is observable and easily correctable. As a result, the
degree of emotional distress and impairment, rather than
the specific nature of the defect, may be more accurate in­
dicators of BDD in these patients.10,11,24,58,71–73
In addition, the degree and psychosocial consequences
of dissatisfaction should also be assessed. Asking about the
amount of time spent thinking about a feature or the activi­
ties missed or avoided may indicate the degree of distress
and impairment a person is experiencing and may help de­
termine the presence of BDD.
Motivations and Expectations
The treating surgeon should also inquire about patients’
motivations and expectations for cosmetic treatment. In as­
sessing patients’ motivations for surgery, the surgeon may
want to begin by asking, “When did you first think about
changing your appearance?” Similarly, it may be instructive
to ask, “What other things have you done to improve your
appearance?” In addition to providing 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. It
is not uncommon for cosmetic surgery patients to report
that they have tried several do-it-yourself treatments, such
as those found on the Internet, in an attempt to improve
their appearance—many of which may be unhelpful and
potentially dangerous.43
Patients should be asked how romantic partners, fam­
ily members, and close friends feel about the decision to
change a physical feature. Although these individuals likely
influence patients’ decision-making process, their role may
not need a psychological evaluation before undergoing a cos­
metic treatment.
Patients who display symptoms of psychopathology
during their initial consultation for cosmetic medical treat­
ment, as well as those with a history of psychopathology, are
most likely to be referred to 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 sur­
gery.5,20 Thus a detailed assessment of patients’ parental re­
lationships and decades old historical experiences is unlikely
to provide useful information to either the mental health
professional or referring surgeon in determining appropri­
ateness for surgery. Rather, a more straightforward evalu­
ation of patients’ current functioning, as found in a more
general cognitive-behavioral assessment, is recommended.70
A trusted mental health professional can be a valuable
consultant to a plastic surgery practice. This mental health
professional should have a good understanding of the psy­
chological aspects of cosmetic surgery, as well as knowledge
of disorders with a body image component, such as BDD and
eating disorders. In most cases, the mental health profes­
sional 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
if the patient is dissatisfied with an objectively successful
outcome or if the patient experiences a significant postop­
erative complication.
Cosmetic surgery patients may react to a referral to a
mental health professional with anger and defensiveness,
believing that they will only feel better if they look better,
and therefore may refuse to go to the consultation. To in­
crease the likelihood that the patient will accept the refer­
ral, 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
information also should be shared with the mental health
professional.
Psychiatric History and Status
The assessment of the patient’s psychiatric history and cur­
rent status should be the central part of the consultation
with a new patient. With the exception of BDD, no con­
clusive data exist regarding the prevalence of psychiatric
diagnoses among persons who seek or undergo cosmetic
surgery. As noted previously, all of the major psychiatric
diagnoses can likely be found in this patient population.
Particular attention should be paid to disorders with a
body image component, such as eating disorders and so­
matoform disorders, and to mood and anxiety disorders.
The presence of these disorders, however, may not be an
absolute contraindication for cosmetic surgery. In the ab­

SECTION I INTRODUCTION
20
cluding depression, eating disorders, or BDD) that was not
identified preoperatively.
Patients in each of these examples may benefit from a
referral to a mental health professional, who often can un­
dertake a more formal assessment of psychopathology and
provide psychotherapy to address the dissatisfaction or psy­
chopathology. The availability of a mental health profes­
sional with interest in working in collaboration with a plas­
tic surgeon can be a valuable resource to the surgeon. The
surgeon must make referrals to mental health professionals
with thoughtfulness and empathy. Efforts should be made
to destigmatize the referral and, at the same time, commu­
nicate to the patient that the surgeon is not abandoning care
of the patient.
Conclusion
Plastic surgeons have long been interested in the psycho­
social functioning of their patients. The earliest writings
in this area, well before the tremendous growth of the
specialty, generally suggested that patients were highly
psychopathological. As cosmetic procedures have become
more common and culturally accepted, this perception has
changed. Individuals who present for cosmetic procedures
are not seen with the same degree of suspiciousness as
they previously were. Furthermore, most of the more con­
temporary research has suggested that there are relatively
few differences between individuals who seek cosmetic
procedures and those who do not. The most consistent
difference seems to be increased body image dissatisfac­
tion, which is the catalyst for a cosmetic treatment. En­
couragingly, many patients report improvements in their
body image after a cosmetic treatment. However, a small
yet significant percentage of patients appear to have BDD.
Others likely have eating disorders or depression. All three
conditions should be evaluated by surgeons preoperatively.
Psychosocial functioning also should be monitored post­
operatively, because patients can experience an exacerba­
tion of these symptoms, sometimes with dramatically un­
favorable results, such as threats of legal action, physical
harm, or suicidal behavior. These outcomes underscore the
importance of the surgeon being mindful of psychosocial
status and functioning throughout the continuum of care
for cosmetic patients.
not be as great as intuitively believed. Breast augmentation
patients reported that their decision to seek surgery was
influenced more by their own feelings about their appear­
ance than by the thoughts of their romantic partners.23,65
Nevertheless, patients who seek treatment specifically to
please a current partner or attract a new one are less likely
to be satisfied with their postoperative 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. There is no current evidence suggesting that cos­
metic procedures directly affect interpersonal relationships.
Therefore patients should be reminded that predicting how
others will respond to their changed appearance is impos­
sible. Some patients may find that few people notice the
change in their appearance, while others may believe that
everyone seems to notice them. Although some patients may
find this attention pleasurable, others may find it uncom­
fortable. To assess this issue, patients should be asked how
they anticipate their lives will be different after surgery. The
experience of unmet postoperative expectations is another
possible explanation of the relationship between cosmetic
breast augmentation and suicide.9,55 Some women may pre­
sent for breast augmentation surgery with unrealistic expec­
tations about the effect that the procedure will have on their
romantic relationships or daily functioning. When these ex­
pectations are not met, they may become despondent, de­
pressed, and potentially suicidal.
Postoperative Psychological Issues
Patients also may experience psychological issues post­
operatively. Most patients likely experience some type of
adjustment reaction to the surgical procedure or postop­
erative recovery and experience the “postoperative blues”
for a few days. Clinical experience suggests that this may be
common among very busy individuals who, a week or two
after surgery, have experienced some return of energy and
stamina, but may not be ready to return to full-time work
and may be growing anxious while feeling 80 to 90% of full
strength. Others may report dissatisfaction with a techni­
cally successful procedure (from the surgeon’s perspective).
This can be suggestive of BDD. Still others may experience
an exacerbation of several forms of psychopathology (in­
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cial outcomes for patients seeking cosmetic surgery. Plast
Reconstr Surg 2004;113(4):1229–1237
9. Sarwer DB. The psychological aspects of cosmetic breast
augmentation. Plast Reconstr Surg 2007;120(7,Suppl 1):
110S–117S
10. Sarwer DB, Crerand CE. Body image and cosmetic medical
treatments. Body Image 2004;1(1):99–111
11. Sarwer DB, Crerand CE, Gibbons LM. Body dysmorphic
disorder. In: Nahai F, ed. The Art of Aesthetic Surgery. St
Louis, MO: QMP; 2005
12. Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psy­
chological investigations in cosmetic surgery: a look back
and a look ahead. Plast Reconstr Surg 1998;101(4):1136–
1142
13. Sarwer DB, Crerand CE, Magee L. Cosmetic surgery and
changes in body image. In: Cash TF, Smolak L, eds. Body
Image: A Handbook of Science, Practice, and Prevention.
New York: Guilford Press; 2011:394–403
14. Grogan S. Body image and health: contemporary perspec­
tives. [Review]. J Health Psychol 2006;11(4):523–530
15. Cash TF, Smolak L. Body Image: A Handbook of Science,
Practice, and Prevention. New York: Guilford Press; 2011
16. Sarwer DB, Gibbons LM, Magee L, et al. A prospective,
multi-site investigation of patient satisfaction and psy­
chosocial status following cosmetic surgery. Aesthet Surg
J 2005;25(3):263–269
17. Frederick DA, Lever J, Peplau LA. Interest in cosmetic sur­
gery and body image: views of men and women across
the lifespan. Plast Reconstr Surg 2007;120(5):1407–1415
18. Pertschuk MJ, Sarwer DB, Wadden TA, Whitaker LA. Body
image dissatisfaction in male cosmetic surgery patients.
Aesthetic Plast Surg 1998;22(1):20–24
19. Sarwer DB, Bartlett SP, Bucky LP, et al. Bigger is not always
better: body image dissatisfaction in breast reduction
and breast augmentation patients. Plast Reconstr Surg
1998;101(7):1956–1961, discussion 1962–1963
20. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA.
Body image dissatisfaction and body dysmorphic disor­
der in 100 cosmetic surgery patients. Plast Reconstr Surg
1998a;101(6):1644–1649
21. Sarwer DB, Whitaker LA, Wadden TA, Pertschuk MJ. Body
image dissatisfaction in women seeking rhytidectomy or
blepharoplasty. Aesthet Surg J 1997;17(4):230–234
22. Simis KJ, Verhulst FC, Koot HM. Body image, psychoso­
cial functioning, and personality: how different are ado­
lescents and young adults applying for plastic surgery? J
Child Psychol Psychiatry 2001;42(5):669–678
23. Didie ER, Sarwer DB. Factors that influence the decision to
undergo cosmetic breast augmentation surgery. J Wom­
ens Health (Larchmt) 2003;12(3):241–253
24. Sarwer DB, LaRossa D, Bartlett SP, Low DW, Bucky LP,
Whitaker LA. Body image concerns of breast augmenta­
tion patients. Plast Reconstr Surg 2003;112(1):83–90
25. Ellison JM, Steffen KJ, Sarwer DB. Body contouring af­
ter bariatric surgery. [Review]. Eur Eat Disord Rev 2015;
23(6):479–487

SECTION I INTRODUCTION
22
60. Goldacre M, Seagroatt V, Hawton K. Suicide after dis­
charge from psychiatric inpatient care. Lancet 1993;342
(8866):283–286
61. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to
socioeconomic, demographic, psychiatric, and familial
factors: a national register-based study of all suicides in
Denmark, 1981-1997. Am J Psychiatry 2003;160(4):765–
772
62. Park AJ, Chetty U, Watson AC. Patient satisfaction follow­
ing insertion of silicone breast implants. Br J Plast Surg
1996;49(8):515–518
63. Schlebusch L, Mahrt I. Long-term psychological sequelae
of augmentation mammoplasty. S Afr Med J 1993;83(4):
267–271
64. Banbury J, Yetman R, Lucas A, Papay F, Graves K, Zins JE. Pro­
spective analysis of the outcome of subpectoral breast aug­
mentation: sensory changes, muscle function, and body
image. Plast Reconstr Surg 2004;113(2):701–707, discus­
sion 708–711
65. Cash TF, Duel LA, Perkins LL. Women’s psychosocial out­
comes of breast augmentation with silicone gel-filled
implants: a 2-year prospective study. Plast Reconstr Surg
2002;109(6):2112–2121, discussion 2122–2123
66. Sihm F, Jagd M, Pers M. Psychological assessment before
and after augmentation mammaplasty. Scand J Plast Re­
constr Surg 1978;12(3):295–298
67. Imadojemu S, Sarwer DB, Percec I, et al. Influence of sur­
gical and minimally invasive facial cosmetic procedures
on psychosocial outcomes: a systematic review. [Review].
JAMA Dermatol 2013;149(11):1325–1333
68. Sarwer DB. Psychological assessment of cosmetic surgery
patients. In: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn
RM, Persing JA, Whitaker LA, eds. Psychological Aspects
of Reconstructive and Cosmetic Plastic Surgery: Clinical,
Empirical, and Ethical Perspectives. Philadelphia, PA: Lip­
pincott Williams and Wilkins; 2006
69. Sarwer DB. Cosmetic surgery. In: Block AR, Sarwer DB,
eds. Presurgical Psychological Screening: Understanding
Patients, Improving Outcomes. Washington, DC: Ameri­
can Psychological Association; 2013:253–271
70. Sarwer DB, Sayers SL. Behavioral interviewing. In: Bellack
AS, Hersen M, eds. Behavioral Assessment: A Practical
Handbook. 4th ed. New York: Pergamon; 1998:63–78
71. Grossbart TA, Sarwer DB. Cosmetic surgery: surgical
tools—psychosocial goals. Semin Cutan Med Surg 1999;
18(2):101–111
72. Sarwer DB, Pertschuk MJ. Cosmetic surgery. In: Kornstein
SG, Clayton AH, eds. Textbook of Women’s Mental Health.
New York: Guilford Press; 2002
73. Sarwer DB, Magee L, Crerand CE. Cosmetic surgery and
cosmetic medical treatments. In: Thompson JK, ed. Hand­
book of Eating Disorders and Obesity. Honoken, NJ: John
Wiley and Sons; 2004:718–737
43. Veale D. Outcome of cosmetic surgery and ‘DIY’surgery in
patients with body dysmorphic disorder. Psychiatrist Bul­
letin 2000;24(6):218–220
44. Veale D, Ennis M, Lambrou C. Possible association of body
dysmorphic disorder with an occupation or education in
art and design. Am J Psychiatry 2002;159(10):1788–1790
45. Crerand CE, Menard W, Phillips KA. Surgical and minimal­
ly invasive cosmetic procedures among persons with body
dysmorphic disorder. Ann Plast Surg 2010;65(1):11–16
46. Picavet VA, Gabriëls L, Grietens J, Jorissen M, Prokopakis
EP, Hellings PW. Preoperative symptoms of body dysmor­
phic disorder determine postoperative satisfaction and
quality of life in aesthetic rhinoplasty. Plast Reconstr Surg
2013;131(4):861–868
47. Phillips KA, Menard W. Suicidality in body dysmorphic
disorder: a prospective study. Am J Psychiatry 2006;163(7):
1280–1282
48. Sarwer DB. Awareness and identification of body dysmor­
phic disorder by aesthetic surgeons: results of a survey of
american society for aesthetic plastic surgery members.
Aesthet Surg J 2002;22(6):531–535
49. Sarwer DB, Spitzer JC, Sobanko JF, Beer KR. Identification
and management of mental health issues by dermatologic
surgeons: a survey of American Society for Dermatologic
Surgery members. Dermatol Surg 2015;41(3):352–357
50. Lynn v. Hugo. Supreme Court, Appellate Division, First De­
partment, New York. 2000
51. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic
disorder and cosmetic surgery. [Review]. Plast Reconstr
Surg 2006;118(7):167e–180e
52. Phillips KA. Treating body dysmorphic disorder using
medication. Psychiatr Ann 2004;34(12):945
53. Sarwer DB, Zanville HA, LaRossa D, et al. Mental health
histories and psychiatric medication usage among per­
sons who sought cosmetic Surgery. Plast Reconstr Surg
2004;114(7):1927–1933, discussion 1934–1935
54. Jacobsen PH, Hölmich LR, McLaughlin JK, et al. Mortality
and suicide among Danish women with cosmetic breast
implants. Arch Intern Med 2004;164(22):2450–2455
55. Sarwer DB, Brown GK, Evans DL. Cosmetic breast augmen­
tation and suicide. Am J Psychiatry 2007;164(7):1006–
1013
56. Brinton LA, Lubin JH, Burich MC, Colton T, Hoover RN.
Mortality among augmentation mammoplasty patients.
Epidemiology 2001;12(3):321–326
57. McLaughlin JK, Wise TN, Lipworth L. Increased risk of sui­
cide among patients with breast implants: do the epide­
miologic data support psychiatric consultation? Psycho­
somatics 2004;45(4):277–280
58. Sarwer DB. Invited discussion: Causes of death among Finn­
ish women with cosmetic breast implants, 1971–2001.
Ann Plast Surg 2003;51(4):343–344
59. Appleby L, Shaw J, Amos T, et al. Suicide within 12 months
of contact with mental health services: national clinical
survey. BMJ 1999;318(7193):1235–1239

Legal and
Safety Issues
S E C T I O N I I

Statue of Themis (goddess of justice) from the temple of Nemesis in Rhamnous, Greece c. 300 BC.
(National Archaeological Museum, Athens, Greece. © Hellenic Ministry of Culture and Sports/Archeological
Receipts Fund. Photo: Klaus Valtin von Eickstedt.)

25
Biomedical ethics guide physicians in making the challeng­
ing moral decisions associated with delivering appropriate
health care. Each specialty has a unique set of ethical issues,
yet they all follow one or more guiding frameworks for con­
temporary medical practice.1 In this chapter, we address
the complexities of biomedical ethics specifically associ­
ated with the practice of plastic surgery. Fields of medicine
associated with aesthetics are being fueled by increased
consumer demand, in part because of the effects of the
media and a society that is greatly concerned with image
and appearance.2 The specialty of plastic surgery requires a
particularly mindful approach so that professionalism and
the physician–patient relationship are held in high regard
and the patient is free from exploitation. Unlike many other
physicians, plastic surgeons can provide aesthetic changes
or other physical alterations that may be deemed unneces­
sary for proper physiologic function. Furthermore, there is
a level of subjectivity involved in the decisions related to
whether plastic surgery should be provided. These issues
are the focus of this discussion.
In general, biomedical ethics can be defined as the study
of morality in medicine, and this morality concerns both
character and behavior.3 One guiding framework for contem­
porary medical practice has been crafted as four principles
bridging low-level morality with high-level morality. Pub­
lished in the Principles of Biomedical Ethics, Beauchamp and
Childress3 established respect for autonomy, beneficence,
nonmaleficence, and justice as the core values underpinning
modern medical and surgical practice.
Respect for autonomy is reflected in medical practice
through the consent process. This is not merely obtained by
just getting a signature on a preprinted form; the surgeon
must explain all the associated risks of surgery, particularly
when, as in plastic surgery, the patient is not necessarily ex­
periencing an illness. Beneficence-based clinical judgment
identifies the moral obligation to act in the best interest of
the patient.4 This is complex in plastic surgery, where iden­
tifying the best interest is often a subjective determination.
Nonmaleficence protects the patient from harm and negli­
gence. In plastic surgery, the challenge may lie in a patient’s
expectations or complications, sometimes because of exist­
ing medical conditions. The concept of justice requires that
access to care be equitable. Because most aesthetic proce­
dures are elective, the ability to pay and the sale of services
is an especially complex matter.
A surgeon who repairs a cleft lip, performs postmastec­
tomy reconstruction, or restores craniofacial structures after
an accident may be confident that he or she is eliminating a
defect or restoring a body part to a baseline level of function
or appearance. These types of reconstructive surgery raise
the typical ethical issues related to access, consent, and the
surgeon–patient relationship. On the other hand, cosmetic
surgery has as its primary ethical challenge the fact that
such service may not be accessible to all patients because of
economic, social, or geographic limitations. In these cases,
an unfavorable outcome is typically limited to incomplete
restoration of function, increased pain, infection, or physi­
cian error. Although the results may not be as aesthetically
appealing as the patient expected, they will typically be an
improvement over the presurgical appearance.
On the other hand, plastic surgeons who perform the
more common elective surgeries such as blepharoplasty,
rhytidectomy, rhinoplasty, abdominoplasty, augmenta­
tion mammoplasty, or body contouring procedures (to
name a few) may be doing so to improve a patient’s sense
of personal aesthetics. Although there may be an unfavor­
able result or some form of error that impairs a function
or degrades an appearance, an ethical and reputable plastic
surgeon will engage in conversations with the patient re­
garding the potential risks and will receive informed con­
sent.
In considering the use of plastic surgery as a panacea for
personal and relationship issues or other social pressures,
the plastic surgeon may face an ethical dilemma. Therefore
Ethics and Plastic Surgery Practice
Kenneth W. Goodman and David J. Birnbach
CHAPTER
4

SECTION II LEGAL AND SAFETY ISSUES
26
This last is often the most difficult to manage, and it is
especially tricky in the case of cosmetic procedures. In ordi­
nary, nonemergency reconstructive procedures, the consent
process is usually straightforward. The surgeon informs the
patient of known risks, anticipated benefits, and alterna­
tive procedures; highlights anything distinctive about the
procedure or the products to be used (the use of fillers or
dressings with biological materials—i.e., synthetic mesh);
and makes it easy for the patient to ask questions. In both
noncosmetic and cosmetic procedures, there are two over­
arching challenges: Demonstration of technical proficiency
to the best of one’s ability and patient satisfaction with the
resulting appearance. Assuming the surgeon’s proficiency,
a lack of error, and the fact that the valid consent process
was clear about risks, the patient may have few options if
the desired result is not achieved, except perhaps a correc­
tive procedure.
In both cosmetic and noncosmetic cases, however, pa­
tient dissatisfaction regarding aesthetics is much more
difficult to address and manage. In cosmetic surgery, the
challenge of such dissatisfaction rises to an extraordinary
level—so much so that in seeking to prevent “unfavorable
results,” the tools and requirements of valid consent are
stretched to the limit; indeed, in some cases, the consent
process may not be up to the task. There are two reasons for
this. The first is that the procedure was not medically nec­
essary in the first place. The second is unrealistic expecta­
tions; in some cases, even patients with adequate capacity
to consent to surgery have very poor insight.
Cosmetic surgery has long posed ethical challenges and
indeed been subjected to criticism and sometimes regarded
as a peripheral medical practice5:
Although increasingly popular, cosmetic surgery is a most
unusual medical practice. Invasive surgical operations per­
formed on healthy bodies for the sake of improving appear­
ance lie far outside the core domain of medicine as a pro­
fession dedicated to saving lives, healing, and promoting
health. These cosmetic procedures are not medically in­
dicated for a diagnosable medical condition. Yet they pose
risks, cause side effects, and are subject to complications . . .
This negative perception of elective aesthetic surgery has
been blamed in part on the media and the “flashy” behav­
ior of some aesthetic plastic surgeons.6 Nonetheless, many
plastic surgeons enjoy favorable reputations and stake their
professional name on building good relationships with pa­
tients and performing appropriate surgeries as determined
by the surgeon with their patient. In the end, the work of
a plastic surgeon is in plain sight, so surgeons serve their
own self-interest by governing themselves accordingly.
Even with a comprehensive disclosure of surgical risks—
including the possibility of aesthetic disappointment—as
part of the valid consent process, some patients will be dis­
satisfied. Most cosmetic surgeons have had the experience
of performing a near-perfect rhinoplasty or breast augmen­
tation but nonetheless ultimately having a disappointed pa­
these patients should undergo a very thorough preoperative
assessment.3 Ultimately, however, if the patient has been
properly evaluated and provides a solid rationale (even if
it is just to look better), the plastic surgeon has fulfilled the
ethical obligation.
Ethical Foundations and
Practical Tools
The foundations of full disclosure and valid consent can be
especially challenging in plastic surgery. Valid consent en­
tails three components (Box 4.1).
These criteria evolved over decades of debate and analy­
sis regarding human subject research and clinical practice.
They are universally accepted and have come to shape the
laws governing research and practice. This is as it should be;
ethics precedes the law to establish the criteria legislators
use in determining what behaviors are permitted, required,
or forbidden. The three criteria for valid consent are jointly
required: It would be a mistake to regard the consent pro­
cess as valid if one were to inform an incapacitated patient
of risks, benefits, and alternatives or to allow a family mem­
ber to exert undue pressure on an informed and capacitated
patient. For this reason, the term “valid consent” is prefer­
able by many to “informed consent,” which highlights only
one of the three criteria; indeed, the lack of capacity or vol­
untariness invalidates the consent of a patient who has re­
ceived adequate information. Note also that these are the
same criteria for “valid refusal,” such that if a capacitated,
informed, and free-acting patient refuses treatment, that re­
fusal should generally be honored.
The literature on each of these three criteria is vast and
analyzes best practices in the event of failure of any of the
three criteria. Generally, if a patient has received inadequate
information, the surgeon should communicate better and
ensure that such communication is part of a process and
not a single event that concludes with the signing of a legal
consent document; if a patient is being pressured or coerced
into receiving or refusing a procedure, the surgeon must re­
assure the patient that the choice is his or hers and try to
assist in eliminating the source of the inducement; and, if a
patient lacks capacity, either functionally or by legal crite­
ria, the surgeon must seek the help of a surrogate or proxy.
Box 4.1
1. Adequate information so a typical patient can
make a reasoned decision whether to proceed
2. Cognitive capacity or, generally, the ability to
understand and appreciate that information
3. Voluntariness, or freedom from beguilement,
undue pressure, or even coercion
Three Components of Consent

27
Chapter 4 Ethics and Plastic Surgery Practice
However, caution is recommended before a surgical in­
tervention to improve appearance. Although peers can be
cruel, fitting in socially has significant advantages, and life is
sometimes unkind, such observations will not always—and
should perhaps rarely—be used as justification for a surgi­
cal intervention. Ultimately, psychological suffering is not
always best addressed surgically. Furthermore, what may be
best for one patient might not be best, appropriate, or even
permissible for others in a similar situation. The distinction
among surgical options for any patient must be drawn care­
fully and based on the following uncontroversial criteria,
based on the list of presurgical questions to be asked by the
plastic surgeon:
•• Medical or psychological need
•• Likelihood of success
•• Availability of less-invasive alternatives
From an ethical perspective, all three should be considered.
It would, for instance, be problematic to undertake an aes­
thetic procedure with little or no chance of success, or if a
minor change in lifestyle could potentially accomplish the
same thing.
It follows that a major surgical intervention should not
be scheduled until a patient has at least considered appro­
priate counseling. If a patient rejects counseling, that can be
a sign of either a well-adjusted person who knows what he
or she wants, or alternatively someone setting himself or
herself up for precisely the kind of unfavorable result that is
feared. Simply stated, to be patient-centered does not consist
in doing everything a patient asks, because some capacitated
patients might make requests that are irrational or poten­
tially dangerous.
This concept evolves into an even more complex area of
concern: the development of the field of “elective medicine,”
which involves performing numerous types of body modifi­
cations outside what is considered conventional. The inten­
tional modification of one’s appearance now goes beyond
tattooing and piercing and includes subdermal implants to
simulate horns and provide other embellishments. Other
tient. Such frustrations can in principle be mitigated or re­
duced by careful preoperative discussions7 (Box 4.2).
The question of “social costs” or social suffering must
also be addressed, because such suffering is commonly cited
as a motivation by patients and a justification by surgeons—
especially in the case of minors, as signaled by this preopera­
tive consent checklist. There are instances of noses so large
or breasts so asymmetrical that a case can be made for their
correction, even if the noses or breasts function normally.
Such a case can even be made when there is no function at
all. Consider this personal anecdote8:
When does one not have a belly button? I once had a pa­
tient who didn’t as a result of very severe and extensive
burns in childhood. When I met him he was 15, and he was
bent at the hip, his collar bone touching the contralateral
knee, such were the retractions. The boy was bent, folded,
and he fought like hell to have a life. Of course he was poor,
of course he came from the countryside. He was evacuated
to my hospital, and the plastic surgeons swung into action;
there was work for everybody—but in about two years the
boy was unfolded, ironed out, grew about 30 centimeters,
and I was invited to his last operation. After the ceremony
of Z-plastying his last abdominal retraction, which would
give him a flat abdomen, instead of a ridged horror, the sur­
geon was closing and he asked me if I thought he should
make him a belly button. No big deal, just a cushion stitch.
I said yes; everybody else said no: he was already 9 hours
under on his umpteenth intervention, and even 5 minutes
was too much. “Yes,” I insisted: finish the job, give him par­
ity with the rest of the human race. Would you know it? It
was the thing he thanked us for. Not standing, not walking,
not sex, not having an ordinary life. He wore cropped tops
and chased all the nurses, now that he was equal.
This anecdote suggests that the desire for cosmetic surgery
and subsequent result can both overstate the definition of
medical necessity and understate the measure of personal
happiness that can accompany the remedy of a physical
disfigurement regardless of cause.
Box 4.2
A thoughtful surgeon should assess the following:
•• Purpose for surgery: Is the proposed surgery
realistic? Does the patient seem competent to make
the decision to have surgery?
•• Degree of deformity: Is the deformity noticeable?
Are the patient’s expectations for correction
appropriate?
•• Level of physical maturity: Will the patient grow out
of the deformity?
•• Social costs: Does the patient suffer socially because
of the problem?
•• Patient–parent decision: Are the parents of a child
or adolescent supportive of the surgery? Are the
parents pushing for the surgery against the patient’s
desires?
•• Postoperative patient attitude: Will the patient be
able to adhere to a postoperative regimen?
Preoperative Discussion

SECTION II LEGAL AND SAFETY ISSUES
28
shaped structures with flashing lights to be implanted in
his forehead, these voluntary, autonomous requests do not
impose any sort of duty or obligation on a physician or sur­
geon. Even if this patient were to argue that he would be
distressed or unfulfilled if his doctor did not grant these
requests, it would be irresponsible to grant them. Indeed,
it would be unprofessional to grant such requests, because
they are outside the established boundaries of surgery and
medicine. This is not to suggest that a surgeon who objects
to such requests is demonstrating paternalism or overrid­
ing the patient’s right to self-determination or autonomy. It
is rather to remind all physicians that their status, by virtue
of special education and training, longstanding professional
values, and social oversight in the form of licensing and ac­
creditation, requires the exercise of informed professional
judgment. Such judgment is a filter through which patient
requests must be transmitted.
This does not suggest that a standard rhinoplasty or
breast augmentation is generally to be regarded as inap­
propriate. Rather, thoughtful surgeons should take steps to
encourage patients seeking such procedures to consider that
their desire is culturally shaped and conditioned; that there
is, in fact, nothing wrong with them; that they might very
well, on careful introspection, come to regard the proposed
surgical intervention as unnecessary; and that behavioral
counseling can be useful in coming to acquire a better per­
spective on their desire to be surgically altered. Cosmetic
surgeons should consider developing information sheets
that make these points, include references to professional
or lay resources that address them, and advise that mak­
ing time for reflection sacrifices nothing and might lead to
a different decision.
Children, Advertising, and
Promotion
Circumstances exist in which the plastic surgeon should
simply decline to do as asked. Although different societies
regard adulthood as commencing at different ages, there is
no disagreement on the criteria for valid consent. Minors
are universally and accurately regarded as lacking capacity
to enter into contracts, vote, or consent to elective medical
procedures or biomedical research. Minors are unable to
understand some information crucial to the consent pro­
cess, are easily influenced, and have diminished ability to
weigh risks, potential benefits, and medicosurgical alterna­
tives.17 More important, the bodies and brains of children
and adolescents undergo swift and significant develop­
ment, and any cosmetic surgical intervention carries the
risk of long-term outcomes far worse than not performing
the surgery. In recognition of this, the Food and Drug Ad­
ministration has not approved, and the American Society of
Plastic Surgery has not endorsed, the use of breast implants
in patients younger than 18 years.18
That a culture permits, let alone encourages, adolescents
to receive cosmetic alteration is itself a poor justification for
a surgeon to acquiesce to some of the more extreme of the
body modifications include penile beading and ribs, extra­
ocular implants, and “flesh pocketing” to hold jewelry. No
peer-reviewed medical literature discusses these phenom­
ena, but a number of other sources, such as Wikipedia, are
available.9 An online search of images for surgical body mod­
ification illustrates forked tongues, pointed ears, and a cell-
cultivated ear attached to an arm. It is unclear whether any
of these modifications were performed by licensed plastic
surgeons. According to CNN,10 one surgeon has documented
some of these and reports one kind of procedure he is com­
monly asked to repair: gauge earrings that function to grad­
ually dilate an ear piercing, often to extraordinary size.
Requests for some corrections are closely tethered to
fashion and culture, if not counterculture: “The perception
of female genital beauty is very much culturally dependent.
For example, in Japan the so-called ‘butterfly’ appearance is
greatly admired. In Western society, protruding inner labia
are considered less attractive, whereas in parts of Africa,
the inner labia are deliberately stretched from a young age.
There are also fringe groups in Western society, who stretch
different parts of the genitalia.”11 Nonetheless, the consid­
erable difference between genital mutilation—widely and
correctly condemned and prohibited in the West—and the
kinds of vulvovaginal alterations increasingly requested in
Europe and North America throws in stark relief this par­
ticular challenge.12,13
The evolution of labiaplasty provides a good example of
healthy people with no dysfunction seeking surgical altera­
tions. Although some requests for labiaplasty are said to be
motivated by discomfort during sports and coitus, there is
insufficient epidemiologic data to document the incidence
and prevalence of such requests, or surgeons’ responses to
them.14 What we do have is cautious and reasoned guidance
regarding what has been unhappily called the “quest for the
‘perfect’ vagina,”15 namely the highly regarded opinion from
the American College of Obstetricians and Gynecologists16:
So-called ‘vaginal rejuvenation,’ ‘designer vaginoplasty,’ ‘re­
virgination,’ and ‘G-spot amplification’ are vaginal surgical
procedures being offered by some practitioners. These pro­
cedures are not medically indicated, and the safety and ef­
fectiveness of these procedures have not been documented.
Clinicians who receive requests from patients for such pro­
cedures should discuss with the patient the reason for her
request and perform an evaluation for any physical signs
or symptoms that may indicate the need for surgical in­
tervention. Women should be informed about the lack of
data supporting the efficacy of these procedures and their
potential complications, including infection, altered sensa­
tion, dyspareunia, adhesions, and scarring.
By comparison, if an informed, voluntarily acting and ca­
pacitated patient declines chemotherapy, participation
in a research study, or aggressive end-of-life care, the pa­
tient’s refusal must be honored; indeed, it would likely
and generally be unethical to force a patient in any such
instances. However, if a patient requests an antibiotic for a
viral infection, an opiate for recreational purposes, or horn-

29
Chapter 4 Ethics and Plastic Surgery Practice
in human insecurity and frailty. Such values and standards
are the insights of physicians themselves and not lawyers,
ethicists, or legislators; that is, these values and standards
are and should be seen as internal to the profession.
Conclusion
The history of plastic surgery dates to well before Hip­
pocrates. An ancient and noble profession, it has dramati­
cally improved the lives of countless people through prac­
tice and advocacy. Physicians will continue to face ethical
dilemmas and will need to come to terms with novel chal­
lenges ranging from stem cell–based therapies to increas­
ing numbers of cases of gender reassignment.23–25 These
challenges and temptations rarely pose “ethical dilemmas.”
An ethical dilemma is a situation in which no matter what
one does, one does something wrong. Many ethical chal­
lenges are difficult, but difficulty, and perhaps even the
need for occasional sacrifice, does not qualify as a dilemma.
Plastic surgeons should have ample resources and profes­
sional touchstones to guide practice.
The foundations of valid consent, the legitimacy of ar­
guments for cosmetic surgery, reasoned limits to certain
kinds of procedures, and cornerstone of professional integ­
rity addressed in this chapter are important ethical consid­
erations. The profession’s ancient history regularly elicits
restatements of core values, and they bear close attention.
Lejour’s vision is laudable26:
I would like to see reconstructive and cosmetic surgery
practiced only by well-trained surgeons with high ethi­
cal standards, concerned with the service to their patients
more than with money and self-promotion.
Such ideals should be the goal of all physicians, and they
should be held in particularly high regard to guide and pro­
tect the profession of plastic surgery.
requested procedures. Fashion and culture change. The val­
ues that undergird the profession of plastic surgery do not.
Indeed, some requests for surgical alteration might in fact be
based on conditions with physiologic or pathologic causes,
as in the case of gynecomastia, for instance, and this might
in conjunction with psychological factors provide adequate
warrant for surgery.19 Such warrant is generally, however,
exceptional. For these reasons, purely elective cosmetic or
aesthetic surgery on children should be a very rare excep­
tion.20
In all cases, decisions whether to undertake such sur­
gery should be based on professional standards and the best
interests of patients, not on the financial interests of the sur­
geon. Plastic surgery has been commercialized, perhaps in
part to serve such interests.21 It might be hypothesized and
perhaps assumed that the marketing and advertising of cos­
metic procedures are intended to improve public health or
even the happiness of individuals dissatisfied with their ap­
pearance. Advertising drives demand, and demand increases
business. Yet the practice of advertising and marketing is
now more common for all medical specialties. All physi­
cians should consider the delivery of care as a professional
privilege and not as a purely commercial enterprise, even
if demand for cosmetic surgery can be increased through
advertising.
The issues of marketing and advertising are shaped both
by ethical and professional standards. Regarding ethics, the
values of self-effacement, patient-centeredness, and social
commitment, including public health, should guide medical
practice. With respect to professionalism, because of a sur­
geon’s special training, accreditation, and licensing, the pro­
fessional must disregard profit-motivated commerce.22 This
is not to argue that physicians may not earn a handsome liv­
ing; however, such a living, being based on the misfortunes
of the sick, injured, or disfigured, should be acquired by ex­
cellent practice and not because of boastful self-promotion
(sometimes by those with dubious qualifications) that trades
References
1. Chervenak FA, McCullough LB, Birnbach DJ. Ethics: an es­
sential dimension of clinical obstetric anesthesia. Anesth
Analg 2003;96(5):1480–1485
2. Mousavi SR. The ethics of aesthetic surgery. J Cutan Aes­
thet Surg 2010;3(1):38–40
3. Beauchamp TL, Childress JF. Principles of Biomedical Eth­
ics. 7th ed. New York: Oxford University Press; 2013
4. Gupta S. Ethical and legal issues in aesthetic surgery. In­
dian J Plast Surg 2012;45(3):547–549
5. Miller FG, Brody H, Chung KC. Cosmetic surgery and the
internal morality of medicine. Camb Q Healthc Ethics
2000;9(3):353–364
6. Atiyeh BS, Rubeiz MT, Hayek SN. Aesthetic/Cosmetic sur­
gery and ethical challenges. Aesthetic Plast Surg 2008;
32(6):829–839, discussion 840–841
7. Bermant MA. Ethics of cosmetic plastic surgery in adoles­
cents. Virtual Mentor 2005;7(3)
8. Dr. Joana Namorado, personal communication.
9. Wikipedia. Implant (body modification).
wikipedia.org/wiki/Implant_%28body_modification%2,
accessed July 2017
10. Youn A. Body modification—or mutilation? CNN News,

modification/, accessed July 2017
11. Scholten E. Female genital cosmetic surgery—the future. J
Plast Reconstr Aesthet Surg 2009;62(3):290–291
12. Sheldon S, Wilkinson S. Female genital mutilation and
cosmetic surgery: regulating non-therapeutic body modi­
fication. Bioethics 1998;12(4):263–285
13. Essén B, Johnsdotter S. Female genital mutilation in the
West: traditional circumcision versus genital cosmetic
surgery. Acta Obstet Gynecol Scand 2004;83(7):611–613
14. Goodman MP. Female genital cosmetic and plastic sur­
gery: a review. J Sex Med 2011;8(6):1813–1825

SECTION II LEGAL AND SAFETY ISSUES
30
22. Fan KL, Thaller SR. Professionalism in plastic surgery. J
Craniofac Surg 2012;23(2):355–357
23. Nayar HS, Caplan AL, Eaves FF, Rubin JP. The ethics of
stem cell-based aesthetic surgery: attitudes and percep­
tions of the plastic surgery community. Aesthet Surg J
2014;34(6):926–931
24. Anderson S. disorders of sexual differentiation: ethical
considerations surrounding early cosmetic genital sur­
gery. Pediatr Nurs 2015;41(4):176–186
25. Selvaggi G, Giordano S. The role of mental health pro­
fessionals in gender reassignment surgeries: unjust dis­
crimination or responsible care? Aesthetic Plast Surg
2014;38(6):1177–1183
26. Lejour M. Looking back at 50 years of plastic surgery. Plast
Reconstr Surg 2007;120(7):2106–2109
15. Cosmetic gynecology and the elusive quest for the “per­
fect” vagina. Obstet Gynecol 2012;119(6):1083–1084
16. Committee on Gynecologic Practice, American College of
Obstetricians and Gynecologists. ACOG Committee Opin­
ion No. 378: Vaginal “rejuvenation” and cosmetic vaginal
procedures. Obstet Gynecol 2007;110(3):737–738
17. Hilhorst MT. Philosophical pitfalls in cosmetic surgery:
a case of rhinoplasty during adolescence. Med Humanit
2002;28(2):61–65
18. Crerand CE, Magee L. Cosmetic and reconstructive breast
surgery in adolescents: psychological, ethical, and legal
considerations. Semin Plast Surg 2013;27(1):72–78
19. Greydanus DE, Matytsina L, Gains M. Breast disorders in
children and adolescents. Prim Care 2006;33(2):455–502
20. Singh K. Cosmetic surgery in teenagers: to do or not to do.
J Cutan Aesthet Surg 2015;8(1):57–59
21. Swanson E. The commercialization of plastic surgery. Aes­
thet Surg J 2013;33(7):1065–1068

31
Informed consent, record keeping, and other forms of docu­
mentation are critical parts in avoiding unfavorable results.
A major source of patient dissatisfaction is failed expecta­
tions. The informed consent interaction is a great time to
explore the patient’s expectations and goals and assess the
ability to deliver such goals. Informed consent is a process
and can be used to help define expectations and document
necessary information. The informed consent process can
be used not only as a legal protection, but also as a means of
adding value and information in assisting the patient with
procedure choices and options.
Avoiding Litigation
Failed expectations are a major reason for litigation. It
behooves the practice to spend an appropriate amount of
time determining realistic expectations of the patient and
the surgeon’s ability to achieve those goals. Patients often
present seeking a certain procedure that they have read or
heard about, but the surgeon should redirect the discus­
sion toward what the patient is concerned about and then
present options to address those concerns. This may or may
not involve the procedure they initially requested. I have
always negated the defense surgeons sometimes use in
litigation, “This is what the patient wanted, and he under­
stood the risks.” This is valid if the choice is an appropriate
one, but surgeons have a duty to protect their patients, of­
ten from themselves. If patient desires a certain procedure,
even after discussion regarding its inappropriateness, the
surgeon still has a duty to provide reasonable and safe op­
tions for the patient. In this time of increased competition,
refusing a patient and risking the loss of that income can be
difficult. The honest and ethical approach is to ensure that
both patient selection and procedure choice are appropri­
ate and obtainable. This does not imply a warranty that the
goal will be reached; it simply affirms the goal is attain­
able given a lack of healing issues and patient compliance.
An appropriate adage is that “you earn your income from
patients you treat, but you earn your reputation often from
those you don’t.”
Informed Consent
Learning styles have a large impact on the informed con­
sent process. The three main learning styles are auditory,
visual, and kinesthetic. Physicians were previously warned
that 35% of information provided is actually retained by the
patient.1 This statistic was based on information that was
spoken to the patient and therefore represents the 35% of
patients who learn from listening. An auditory learner lis­
tens attentively to every detail expressed, often painting in
the mind a picture of what is described. An auditory learner
should be told reasonable aspects of options, choices, pro­
cedures, medications, postoperative care, and other details.
A visual learner requires a visual aid, which may be a pho­
tograph, video, sketch, or other demonstrative. Thus using
such aids would benefit the informed consent process with
the caveat that these models do not guarantee the specific
patient’s result. A kinesthetic learner retains information
best when descriptions are personalized. Examples are
helpful, such as, “Remember when you had a sunburn? A
facial peel or laser treatment may be close to that.” Sur­
geons must be creative in arriving at personal examples
the patient can relate to. These learning styles, when com­
bined, can result in a much higher retention, understand­
ing, and improved choice of ultimate treatment as well as
patient acceptance. All three of these learning styles should
be incorporated in the informed consent process to provide
an appropriate level of information that can be understood
by the majority of patients to help achieve the goal.2,3 Many
patients will not reach a full understanding after one visit.
Often multiple visits are necessary to provide full under­
Informed Consent, Record Keeping,
and Documentation
Neal R. Reisman
CHAPTER
5

SECTION II LEGAL AND SAFETY ISSUES
32
ments, concerns, and impressions of prospective patients
with each other is beneficial. Patients often demonstrate a
certain negative attitude in the reception area only to be
nice and demure in the examination room. This team ap­
proach can reveal the true patient.
A Guide for Patient Selection
Dr. Mark Gorney, past American Society of Plastic Surgeons
President, educator, and liability expert, developed the
Gorneygram to help with patient selection4,5 (Fig. 5.1). This
chart compares actual deformity against the perception of
deformity and is a very useful tool in patient selection. A
patient with a minimal deformity, such as a camouflaged
scar, whose perception is that of a severe debilitating in­
jury raises many red flags about ever achieving satisfactory
results.
For a hypothetical example, Quasimodo, the Hunchback
of Notre Dame, seeks some improvement for his hump. He
desires any improvement and realizes complete removal
and correction is unlikely. He might be placed in the lower
right corner of the dark green section of Fig. 5.1, a favor­
able patient. Ginny, however, seeks correction for a scar on
her cheek that is only barely perceptible with magnifica­
tion × 6 loupes. She is devastated by this scar and often will
not leave her house. Ginny might be placed in the upper
left corner of Fig. 5.1—dark red. It would be very question­
able if Ginny could be helped, no matter the outcome of
her surgery. Although such a graph and the patient selec­
tion process is never absolute, it is a useful guide to assess
a patient’s perception of the issues and the possibility of
achieving the goal.
standing as well as the time to answer questions and in­
teract.
Express Versus Implied Warranty
The surgeon must be careful when using demonstrative vi­
sual examples to not imply that this will represent the pa­
tient’s results. It is common for patients seeking breast aug­
mentation to bring photographs of their desired outcome.
Such photographs should not be included in the medical
record, because doing so may help create an express war­
ranty as to the patient’s results. There are two types of war­
ranty that may be created:
1. The express warranty relies on a demonstrative as
part of a record demonstrating what the surgeon will
achieve. These photographs are helpful in assessing
how realistic the patient’s goals are but not to ever
imply they will be reached. Surgeons should be careful
of other forms of visual aids for the same reason.
2. An implied warranty can be created when a patient
discloses necessary criteria such as time of recovery,
such as a requirement for a future meeting or event,
and specifically stated goals that must be reached. An
example might be a patient stating she must achieve
a size 4 and recover completely to attend a business
cruise 7 days postoperatively. Upon hearing this, the
surgeon should document the negation of the require­
ment that the patient will be a size 4 and be able to
attend the business meeting. The surgeon and patient
should discuss choosing a different date for departure,
as well as the possibility that the size requirement may
not be attained.
Failing to negate and discuss patient demands may lead
to an implied warranty that the demands will be met. The
informed consent process should include a dialogue about
patient goals, recovery, realistic results, complications, and
inherent risks. This process should be repeated when any
treatment is suggested or provided.
The Team Approach
A common question arises when treatment for facial
rhytids involves a toxin. Each toxin-based treatment should
have its own consent, even if the treatments will continue
at certain monthly intervals. The consent process should be
performed mainly by the treating physician if he or she is
providing the service. A team approach is acceptable but
cannot replace the ultimate responsibility of the physi­
cian in delivering the informed consent message. The office
team should maintain consistency by including the same
information and learning-style methods to prevent confu­
sion or missing necessary patient goals. Patients typically
will challenge one member of the team against another if
different information is presented. Establishing an under­
standing among practice team members to share com­
Fig. 5.1 Patients with a lower level of concern versus deformity, rep­
resented by the green area, are typically very acceptable patients.
Conversely, patients who fall in the red area of this graph, because
of a higher level of concern that is warranted by the degree of de­
formity, may pose significant problems and possibly should not be
accepted for treatment. (Adapted from Gorney M, Martello J. Patient
selection criteria. Clin Plast Surg 1999;26[1]:37–40.)
Concern
5
4
3
2
1
Deformity
1
2
3
4
5
Patient Selection Guide

33
Chapter 5 Informed Consent, Record Keeping, and Documentation
dard clinical information and examination results gathered
in the provider’s office. The EHR includes a broader view of
a patient’s care. This poses a significant increase in risk and
interference with the doctor–patient relationship.
Patients typically will not initiate a lawsuit against doc­
tors they like. I have always suggested that, when possible,
surgeons should accept patients into their practice that they
also like. This can be difficult with emergency care and ser­
vices and some managed-care plans. The documentation re­
quirement in EHRs can take the interaction away and leave
the physician’s head stuck in a tablet or laptop. This leads
to one of the two aspects of major risk involved with EHRs:
interference with the doctor–patient relationship. A visit or
consultation should be initiated with dialogue by personally
and interactively asking the patient’s permission to enter
necessary information into the digital record. The surgeon
should take breaks and return to an interactive face-to-face
patient dialogue when possible. All staff in the patient team
should become familiar with such techniques to ensure an
appropriate and adequate practice–patient relationship de­
spite the digital intrusion.
Another concern with EHRs arises from the desire to
expedite data entry with smart text. Default language is cre­
ated, and smart text can be chosen to facilitate data entry.
The challenge is that once data is entered and signed, it be­
comes authenticated and substantiated. If the “default” text
states “No Nipple Discharge—No Masses,” the exam must
mirror that information. It may be confusing if the patient’s
main complaint is listed as “Nipple Discharge,” yet the de­
fault text entry lists “No Nipple Discharge.” The informa­
tion must conform to the actual examination. Defaulting
to a created smart text in a breast examination reveals no
masses and no nipple discharge that must be corroborated
and factual. Commonly used smart text and default entries
must be reviewed to ensure that they accurately reflect ac­
tual findings.
Many patients demand privacy regarding aesthetic
procedures. However, all records of health care are stored
within their EHR. Complaints may be made to the plastic
surgeon when a subsequent provider or health care plan
comments about the so-called “confidential cosmetic sur­
gery.” The plastic surgeon is required to enter data about
cosmetic surgery into the health record. Nothing prevents
an authorized subsequent health care provider or company
from viewing that information. Patients should be made
aware of the completeness and complexity of the digital re­
cord. The Communications Consent document should in­
dicate that all attempts will be made to secure records and
information, but that the complete record will be viewable
by authorized members of the health care team.8,9
Security and accuracy are the best methods of protec­
tion. An honest disclosure of inherent risks of data protec­
tion in addition to consents for patient contact and use of
patient data such as photographs become critical. Surgeons
must be knowledgeable of technology limitations and meth­
ods to delete such information once transferred to a secure
computer or cloud network.
The Digital Record
The digital age contains its own risks and concerns. Digital
photographs and patient information are easily electroni­
cally transmitted yet must be protected. There has been
significant liability with the release and posting of patient
photographs. Even if a signed release liability exists, for a
patient photograph to be used for commercial use, such as a
website or demonstration book in the office, a specific com­
mercial release is required.6,7 The standard Health Insur­
ance Portability and Accountability Act (HIPAA) release to
take and store a photograph is inadequate. Full disclosure
regarding the form, length of time, distribution, and how
the photograph will be used and obtaining specific writ­
ten approval for these aspects are important. Metadata is
stored within the digital information for the photograph,
and unless the metadata is scrubbed or removed, such pri­
vate information may be inappropriately released. It be­
hooves the practice to ensure that such posting or usage of
any photograph, even with written permission, has been
scrubbed of such metadata to ensure a patient’s name and
private information does not become visible when a mouse
pointer is used to hover over the photograph.
Patient Privacy
In the digital age of communication, written consent for
how a patient may be contacted, whether by a telephone,
email, texting, social media, or regular mail at work or home,
is recommended. Such communication consent should be
updated frequently and will hopefully prevent concerns as­
sociated with patient contact. A disclosure indicating the
possibility of a breach of private information that may occur
is also advisable. This is similar to those used in the banking
industry and asserts that the patient will be notified should
a hack or breach occur, that all efforts will be made to pro­
tect their privacy, but such protection is not guaranteed, as
breaches have occurred in even the highest levels of govern­
ment.
If smart phones or similar devices are used for photo­
graphs, emails, or texting, location services and other ap­
plications and settings that may expose critical information
must be turned off. There are applications that can transfer
texts to a main secure computer so they can subsequently
be deleted. Applications are available that place photographs
in secure folders. Keeping the phone locked and using other
encryption methods are also advised.
Electronic Health Records
Electronic health records (EHRs) are another newer factor to
be considered. EHRs differ from electronic medical records
(EMRs). EMRs are a digital version of the paper charts in the
clinician’s office. An EMR contains the medical and treat­
ment history of the patient in a practice. EHRs contain the
information held in the EMR, but also do more. EHRs focus
on the total health of the patient, going beyond the stan­

SECTION II LEGAL AND SAFETY ISSUES
34
As discussed previously, if the surgeon works in a hospital
system with a combined EMR, the record of the cosmetic pro­
cedure is documented. A subsequent health care professional
can review the patient’s EMR and see the augmentation notes.
Many EMR programs do not have a means to make such in­
formation private and marked confidential. The primary care
physician may ask the patient how her augmentation is do­
ing, causing her to become upset with her plastic surgeon for
disclosing this information. If a patient asks for such privacy,
it is important to explain the new EMR and EHR systems that
prohibit a method to mark such requested details as “private.”
A conflict always exists between the medical record and
the legal perception of “if it is not documented, it did not oc­
cur.” The medical record is for the health care team to care
for a patient and allow continuity of care and not a complete
record of all activity. Pertinent information in providing care
should be documented, but all activity during a visit or dur­
ing care is not required to be documented. All information
should be documented as if the physician is leaving the prac­
tice abruptly and someone else has to appropriately care
for the patients. A complete and appropriately documented
record is much easier to defend than a spare record. EMRs
can help with possible illegible writing. However, if records
are dictated, all entries must be reviewed. An interpreta­
tion of “Had No Carcinoma” is quite different from “Adeno­
carcinoma.” Corrections become necessary when incorrect
entries exist, but correction fluid should never be used on a
record. An EMR prevents this. Instead, a contemporaneous
entry should be inserted that a misstatement is present. The
surgeon should correct, sign, date, and time the entry. I do
not suggest using the terms error, mistake, or inadvertent.
Should the care lead to litigation, an attorney can use these
words to ask, “How many other mistakes or errors did you
make, Doctor?” Inadvertent can be defined as “negligent”!
Overly defensive documentation leads to the perception
that the physician is hiding something. However, if a test
is ordered, the surgeon must be able to justify the reason
it was ordered. In other words, anything ordered must be
checked and attempts to resolve a problem must be doc­
umented. The team of care providers works together and
should review each other’s data entries. The same correction
methods stated earlier should be enforced should an entry
require further comment or correction.
Conclusion
Informed consent is a complicated concept in this vastly
changing and complex legal field. One can imagine that
the Affordable Care Act, with its potential for an increasing
number of patients and potential and significant delays and
various nonphysician interactions, may lead to an increase
in litigation. The concepts in this chapter, along with proper
documentation, teamwork, planning, and patient interac­
tion, may diminish that risk.
Electronic Health Record Risks
EHRs pose many risks to the practice. The time stamp of
care can easily be used to demonstrate a superficial discus­
sion and clearly inadequate time for informed consent. The
surgeon may claim he or she spent an hour discussing all
risks and hazards with the proposed procedure, but the
time stamp correctly or incorrectly may depict 20 minutes
of actual time spent on this. This should be continually
evaluated. The strive for efficiency may be difficult to bal­
ance against adequate time spent when necessary.
The record itself can become unmanageable. The vol­
ume of documented information may obscure necessary
test results or other information requiring action. Physicians
should develop a scheme to locate the necessary information
and records, perhaps by creating their own starting page so
patient data is readily available. In addition, as mentioned
previously, smart text means practitioners do not have to
enter actual information about the patient, but can choose
created phrases and click to post entire sections of informa­
tion for any patient. This text must be checked for accuracy.
Sometimes, it may be appropriate to use such smart text
phrases, but the information should be read and approved
before it is signed. Similar issues arise with default entries.
If common answers occur, a default answer may save time
by limiting necessary keystrokes. Again, the default informa­
tion must be verified. Once the record is signed, the post is
permanent, and if it is incorrect, it creates a perception that
the physician either rushes or does not listen to patients (or
worse). A recommended practice is to flag the position of
such smart text so some action or review is required before
they post.
Patient Privacy Dilemma
EHRs create another privacy concern. As mentioned pre­
viously, many patients ask their plastic surgeons to not
disclose their cosmetic procedures, even when combined
with an insurance-covered procedure. This may be an occa­
sion when two operative notes are permissible. Although it
is necessary to refer to each note in the other, specifics may
be left out. For example, a patient has a breast augmenta­
tion and a carpal tunnel procedure, and they are performed
together. The patient does not want the augmentation dis­
closed to her self-insured company, because the insurance
manager is a gossip and she believes the entire office will
then know about the procedure. An operative note is dic­
tated describing the carpal tunnel, and a reference is made
to a separate surgery performed under a different record.
The breast augmentation operative note describes the aug­
mentation and refers to a separate operative note performed
after the augmentation under a separate cover and dicta­
tion. However, the electronic record eliminates that patient
choice. All records are stored in her EHR.

35
Chapter 5 Informed Consent, Record Keeping, and Documentation
Additional Legal Resources
Anderson RE, ed. Medical Malpractice: A Physician’s Sourcebook.
Totowa NJ: Humana Press Inc; 2005
Barton HM. Medical records can win or lose a malpractice case.
Tex Med 1990;86(5):33–36
Berlin L. Alteration of medical records. AJR Am J Roentgenol
1997;168(6):1405–1408
Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice
risk according to physician specialty. N Engl J Med 2011;
365(7):629–636
Nahai F, Reisman N. Pitfalls of online and digital communications
with patients. Plastic Surgery News 2011;129(5S)
Reisman N. Information that can and cannot be shared with col­
leagues. Plastic Surgery Pulse News 2013;5(3)
Reisman N. On Legal Grounds. Plastic Surgery News
“Beauty is Skin Deep – Ugly to the Bone”
“Scrub your Commercial Photographs”
“In Search of Normal Expectations and Return to Attention To
Detail”
“The ADA”
“HER Risk Update”
“Choosing Patients You Like”
“The Electronic Records Information Trap”
“Babe Ruth Syndrome”
Rinker B, Donnelly M, Vasconez HC. Teaching patient selection in
aesthetic surgery: use of the standardized patient. Ann Plastic
Surg 2008;61(2):127-131, discussion 132
References
1. Wirshing DA, Wirshing WC, Marder SR, Liberman RP, Mintz
J. Informed consent: assessment of comprehension. Am J
Psychiatry 1998;155(11):1508–1511
2. Gardner H. Multiple Intelligences: The Theory In Practice, a
Reader. New York: Basic Books; 1993
3. Lane C. Gardner’s multiple intelligences: the distance learning
technology resource guide. tecweb.org/styles/
gardner.html
4. Gorney M, Martello J. Patient selection criteria. Clin Plast
Surg 1999;26(1):37–40, vi
5. Gorney M. Ten years’ experience in aesthetic surgery mal­
practice claims. Aesthet Surg J 2001;21(6):569–571
6. HIPAA Section 164.514(b)(2)
7. Standards for Privacy of Individually Identifiable Health In­
formation; Final Privacy Rule Preamble. 45 CFR Parts 160
and 164. Fed Regist 2000;65(250)
8. Haeck P, Gorney M. Electronic Medical Records May Cast
Physicians in Unfavorable Light During Lawsuits. Risk, Li­
ability and Malpractice: What Every Plastic Surgeon Needs
to Know. Philadelphia: Saunders; 2011
9. Barrows RC Jr, Clayton PD. Privacy, confidentiality, and
electronic medical records. J Am Med Inform Assoc 1996;
3(2):139–148

The operating room (OR) is a complex, dynamic work envi­
ronment in which multiple professions must interact with
each other and complicated technologies in a seamless, ef­
ficient manner to ensure safe, effective patient care. Such a
workplace is rife with potential problems and failings that
can negatively impact the delivery of surgical treatments.
These issues are magnified when the interaction of the OR
with surrounding care units (e.g., the intensive care unit
[ICU], the postanesthesia care unit [PACU], the emergency
department [ED]) and the requirements of specialized sur­
gical specialties such as plastic surgery are taken into con­
sideration. Thus the OR and its teams must function like
the proverbial “well-oiled machine” to provide proper care
of the patient.
How does an OR become such a “well-oiled machine” in
which plastic surgical patients receive excellent care consis­
tently? This chapter reviews key concepts related to bringing
such high reliability to the OR and its affiliated care environ­
ments by addressing the following objectives:
1. Defining essential features of high reliability organiza­
tions (HROs)
2. Discussing the role of human factors (HF) in promoting
safe surgical care
3. Applying HF concepts to improve surgical teamwork
and care for patients undergoing plastic surgical inter­
ventions
Organizational Culture and
Adaptation
OR safety does not just “happen.” At its core, it is the result
of creating and maintaining the appropriate culture and
adaptability at the organizational level to ingrain key be­
haviors and attitudes into the involved individuals so safety
supersedes all other concerns. In such a culture of safety,
all necessary resources are devoted to support safety; an
openness regarding recognition of errors and problems
exists; communication is candid and frequent within and
between all levels of the organization; and learning and im­
provement within the organization is encouraged.1
Attaining this cultural state, however, is not a given.
Organizations, like individuals, have different orientations
and depending on which one they possess are more or less
predisposed to adopting cultural traits promoting safety as
the primary priority2 (Table 6.1). A power-based (pathologi­
cal) organizational culture is poorly equipped to adequately
address safety concerns, whereas a rules-based (bureau­
cratic) one often is too caught up in its regulations to adapt
as needed. It is the performance-based (generative) organi­
zational culture that is best suited to promote safety first in
a consistent and effective manner. Getting to this generative
stage from one of the two former cultural states is an ardu­
ous and prolonged process, because cultural change requires
tilting the deep-seated assumptions within the organization
that form the basis of how it functions to shift its values and
behaviors. Such transformation can often take a decade or
more and necessitates using an established change process
strategy in a coordinated, concerted manner. Although dif­
ficult, successful cultural change can be dramatic in nature,
as evidenced when sports teams transform from perennial
losers into consistent winners.
Thus the ultimate goal for attaining safety in health care
is to create HROs that base their activities on performance
and adaptability. HROs are common in other dynamic, high-
risk industries in which lapses and errors can lead to cata­
strophic events. Civil and military aviation, nuclear energy,
offshore oil drilling, chemical production, and space explo­
ration are several examples. Organizations within such in­
dustries, however, are not immune from problems if HRO
Bringing High Reliability
to the Operating Room
John T. Paige
CHAPTER
6
36

37
Chapter 6 Bringing High Reliability to the Operating Room
issues between naval aviators and hospital staff illustrated
the difference between the two professions. Whereas only
1 in 20 naval aviators gave problematic answers to the ques­
tions on their safety survey, 1 in 5 hospital staff in high-risk
departments (e.g., OR, ED) did so. Regrettably, a more recent
look at urology trainees in western Scotland by Geraghty et
al8 revealed that the issue persists today. Almost half of these
trainees felt that safety was the least important item in the
hospitals in which they worked.
As alluded to previously, changing the culture of an en­
tire organization can be daunting. Fortunately, such change
can be attained at the divisional or frontline level of an or­
ganization, thus creating pockets in which safety is the pri­
mary priority. Such news is good for an industry such as
health care thanks to the many characteristics cited as con­
ditions that make it unlikely to achieve HRO status: the di­
versity of tasks and outcomes, the vulnerability of the pa­
tients being treated and the uncertainty of their outcomes,
the numerous activity patterns, and the lack of regulation.9
Thus a clinical microsystem within a hospital or health care
entity (i.e., a group of health care professionals working to­
gether with a shared clinical purpose to provide care to a
defined patient population) can function like an HRO. The
OR is such a microsystem, and, as discussed previously, it
interacts with other clinical microsystems to form a peri­
operative microsystem or service line within a particular
health care entity (Fig. 6.1). It, or the larger perioperative
microsystem within which it is housed, can therefore be
targeted for HRO functioning. Like HROs, well-functioning
clinical microsystems demonstrate characteristics of mind­
fulness over mindlessness, including constancy of purpose,
investment in improvement, role alignment, care team in­
terdependence to meet patient requirements, technology
and information workflow integration, continuous mea­
surement of outcomes, larger organizational support (if it
is an HRO), and strong community relations.10 Whether at
the organizational or microsystem level, however, attaining
principles are not followed. The Deep Water Horizon explo­
sion and oil spill and the radiation leak at the Fukushima
Daiichi Nuclear Power Plant are two relatively recent events
emphasizing this point.3,4
HROs are characterized by key operational principals
and attitudes that allow them to perform consistently and
safely in high-hazard environments. Foremost among them
is a preoccupation with failure. They are constantly looking
for weaknesses in their systems in an attempt to find them
before they surface on their own. Thus HROs show a sensitiv­
ity to operations and a reluctance to simplify interpretations
of events or problems to ensure issues are not missed. In
addition, within such organizations, individuals are much
more inclined to demonstrate a deference to expertise in
lieu of seniority or rank. All these elements combine to al­
low the HRO to have a commitment to resilience when faced
with rapidly changing, high-risk situations that permits the
adaptability necessary to prevent catastrophic events.5
Distilling the principles of an HRO down to a single, en­
compassing concept can be challenging, but it is useful to
help convey the attitudes and behaviors needed within an
organization. Weick and Sutcliffe’s5 emphasis that HROs pro­
mote “mindfulness” in lieu of “mindlessness” is one such ef­
fective distillation of what is necessary. Sutcliffe6 expanded
on this concept by pointing out that HROs are reliability-
seeking entities rather than reliability-achieving ones. Thus
they strive to have high effectiveness in function within
high-risk environments.
Unfortunately, HROs are rare in health care. This fact was
brought home a decade ago by the study by Singer et al1 of
California hospitals in which hospital staff and administra­
tion completing a survey on safety demonstrated problem­
atic responses among almost one fifth of the clinicians and
approximately one sixth of senior managers. Overall, almost
one in five respondents gave problematic answers, far from
the less than 10% frequency required to qualify as a culture
of safety. A follow-up study by Gaba et al7 comparing safety
Table 6.1 Organizational orientations and their characteristics
Organizational orientation
Power-based
Rules-based
Performance-based
Cooperation within
organization
Minimal
Moderate
Maximum
Distribution of
responsibility
Shirked throughout system
Narrowly defined
Shared within system
Reaction to failure
Scapegoating
Search for justice
Inquiry into causes
Treatment of messengers
Shot
Neglected
Trained
Response to errors
Suppression
Local fix
Global fix
Source: Adapted from Westrum R. A typology of organisational cultures. Qual Saf Health Care 2004;13 Suppl 2:ii, 22–27.

SECTION II LEGAL AND SAFETY ISSUES
38
James Reason14 popularized this notion of multiple cir­
cumstances coming together to cause a catastrophic event
with his concept of the Swiss cheese model of error pro­
duction in complex systems. In this model, unknown or un­
noticed weaknesses in the defensive systems within an or­
ganization, known as latent conditions, can align with one
another or with active failures produced by actions and
decisions of individuals to lead to the catastrophic event.
The holes in the layers of defense line up like those in Swiss
cheese to result in an adverse outcome. Sadly, health care
has too many examples of so-called “Swiss cheese in action,”
and the OR is often at the forefront of high-profile events.15,16
Thus the goal of HF engineering is to create systems that
are efficient in avoiding, trapping, and mitigating threats and
errors.17 In other words, they help individuals first identify
and avoid potential threats, then identify and correct cur­
rent threats, and finally identify and limit the damage of er­
rors that do occur.17 Ultimately, HF engineers want to create
systems and processes that elicit desired human behaviors
to mitigate errors (i.e., shape human behavior).13 In doing
so, they can use systems-focused (i.e., technologic) or peo­
ple-focused (i.e., human-centered) approaches. Although the
systems-focused strategies tend to be more effective in gen­
eral, people-focused strategies are necessary to allow the
positive impact of human judgment to remain.13
Decreasing complexity, standardization, intelligent au­
tomation, computerization, optimization of information
processing, and force functioning are all examples of tech­
nologic, systems-focused solutions to reduce error.13,18 Of
these, force functioning, or the imposition of physical con­
straints, is the most effective. Examples of such physical con­
straints are encountered every day, from the inability to fit
a diesel nozzle into the tank of a car that requires unleaded
HRO-like functioning requires an understanding and imple­
mentation of HF principles and techniques, discussed in the
next section.
Human Factors Study and
Team Function
HRO concepts and function have grown out of a field of
study little known to clinicians in the health care industry:
HF. As its name implies, the study of HF focuses on the in­
teraction of humans with their environment. In the typical
workplace, this environment can consist of the technology
with which the individual works, the processes and proce­
dures of the system, and the interaction of each individual
with others in the teams in which they work. Clearly, the
OR and perioperative microsystem are environments in
which these interactions of technology, teams, and pro­
cesses are important.
HF engineering is the application of HF theories to the
real world. Its goal is to design systems and devices for safe,
effective use by humans.11 To achieve this goal, HF engineers
attempt to optimize the interaction of technology, teams,
and processes by learning about human behaviors, abilities,
and limitations.11 Understanding human limitations arises
from one of the foundational axioms of HF: human error is
inevitable, and as a result, an error-free system cannot be
created.12 Defenses-in-depth therefore are needed to min­
imize the negative impact of an error. Another important
belief is, as Cafazzo and St-Cyr13 have stated so eloquently,
“a fundamental rejection of the notion that humans are pri­
marily at fault when making errors in the use of a socio-
technical system.”
Emergency department
Operating room
Surgical wards
Intensive care units*
*Postanesthesia care unit (PACU);
intensive care unit (ICU)
Fig. 6.1 The perioperative microsystem.

39
Chapter 6 Bringing High Reliability to the Operating Room
too early or late, ambiguous messaging occurs (e.g., hinting
at a problem and hoping the person gets it), or information
is not heard by all members. Finally, ineffective communi­
cation occurs throughout the entire surgical care process,33
negatively affecting patient care.34,35
The result of this ineffective teamwork is tension lead­
ing to disruptive behavior and distractions.36,37 These issues
combine to have a negative impact on patient care. Poor
teamwork in the OR has been shown to increase technical
errors,38 lead to higher morbidity and mortality,39 decrease
patient safety,40 and be a major factor in sentinel events.41
Clearly, especially in the OR setting, effective teamwork is
an essential component for providing proper care to surgi­
cal patients.
Applying Human Factors Engineering
to Promote Safe, Effective Surgical Care
By taking an HF engineering approach to the OR and the
perioperative microsystem, a multiprong, comprehensive
strategy can be used to promote HRO principles and func­
tion and allow the provision of safe, effective surgical care.
From an HF perspective, the care of the surgical patient is
set within multiple spheres of influence involving all levels
of an organization and society in general, each of which can
be targeted for interventions to promote patient safety42
(Fig. 6.3). The World Health Organization (WHO) has iden­
tified 10 key HF topics within these various spheres of influ­
ence as the most relevant to target for intervention and has
delineated various tools to help with both measuring and
implementing them42 (Table 6.2). Although the tools and
measures suggested by the WHO are far from comprehen­
gasoline to different-shaped plugs for the power and video
cords on a computer. People-focused interventions include
the use of checklists, double checks, and reminders; policies
and procedures (i.e., procedural constraints); and education
and training.13 Whatever intervention is undertaken by HF
engineers, they must always keep in mind that unwanted
consequences can occur from the implementation of new
strategies, and they must work to prevent them.18
As mentioned previously, one of the most powerful con­
straints that can be employed to trap and mitigate errors in a
system is a culture of safety. Positive and negative examples
of the impact of organizational culture on safety abound.
The nuclear aircraft carrier USS Carl Vinson provides a posi­
tive one. In this dynamic environment, losing anything on
the flight deck can result in catastrophic outcomes if the
lost item is sucked into an engine of a jet. Thus when a sea­
man once lost his wrench and reported it, all planes were
diverted from the carrier, and the flight deck was searched
until the lost item found. The next day, the seaman was rec­
ognized and rewarded for reporting his error at a formal
ceremony.5 The saga of British Petroleum (BP) provides a
negative example. Although it has branded itself as the en­
vironmental company, its focus on profit over safety has re­
sulted in a series of environmentally devastating events: the
Texas City Refinery explosion,19,20 the Prudhoe Bay trans-
Alaska pipeline oil spill,20 and the aforementioned Macondo
well explosion and oil spill in the Gulf of Mexico.3,20
The lynchpin to creating an HRO and promoting a cul­
ture of safety is having highly reliable teams of individuals
within the organization to carry out its function.21 Without
such teams, maintaining the communication and resilience
essential for HRO operation is severely limited. Salas et al22
have identified five key team traits that, with three coordi­
nating mechanisms, are consistently found in highly reliable
teams in high-risk industries such as the military and avia­
tion. These traits interact with the coordinating mechanisms
and each other to produce teams that are able to show resil­
ience and adaptability in high-stress, rapidly changing en­
vironments22,23 (Fig. 6.2). This Big Five Model of Teamwork
serves as the foundation of the Team Strategies and Tools
to Enhance Performance and Patient Safety (STEPPS) devel­
oped by the Department of Defense in coordination with the
Agency for Healthcare Research and Quality.24
As with a culture of safety in health care, highly
­reliable team function is lacking, especially in the OR. A
silo ­mentality combined with tribalism promotes multi­
professional interaction in lieu of true interprofessional
­teamwork.25 This situation is exacerbated by unwanted
­hierarchical structures,26,27 role confusion,28,29 differing
perceptions of teamwork,30,31 and poor communication32 to
undermine team interaction. The lack of effective commu­
nication is especially troublesome because of its resultant
confusion. As with the famous Abbott and Costello “Who’s
on First?” routine, members of the OR speak the same lan­
guage but do not understand one another. OR personnel suf­
fer from information misunderstanding and information
confusion. In addition, information in the OR is often given
Team
leadership
Team
orientation
Mutual
performance
monitoring
Adaptability
Backup
behavior
Closed-loop
communication
Shared mental
models
Mutual
trust
Fig. 6.2 The Big Five Model of Teamwork. Adapted from Salas E,
Sims DE, Burke CS. Is there a big five in teamwork? Small Group Res
2005;36:555–599

SECTION II LEGAL AND SAFETY ISSUES
40
Society, culture, rules
and regulations
Surgical
patient
Health care
organizational structure
World Health Organization
(WHO) targets:
Safety culture
Leadership
Communication
Operating room
teams
Teamwork dynamics
Team leadership
Individual operating
room staff members
Situational awareness
Decision-making
Stress and fatigue management
Operating room
equipment and environment
Workplace hazards
Fig. 6.3 Human factors influence surgical care and interventions. WHO, World health organization.
Table 6.2 World Health Organization top ten human factors topics for
promoting patient safety and tools for them
Human factors topics for
promoting patient safety
Tools and measurements
Organizational/managerial level
Safety culture
Hospital Survey on Patient Safety
Safety Attitudes Questionnaire
Manchester Patient Safety Assessment Framework
Managerial leadership
Multifactor Leadership Questionnaire
Authentic Leadership Questionnaire
Leadership Practices Inventory
“Seeing Yourself as Others See You”
NHS Leadership Qualities Framework
Leadership Guide to Patient Safety
Leadership Checklist for NHS Chief Executives
Patient Safety Walk Rounds Guide and Data Collection Tool
Communication
DOD Handover Tools
“Do Not Use” List
Safety Briefing Tool and SBAR Tool
Safe Handover
Surgical Safety Checklist
DASH Debriefing Tool
Team Self Review Debriefing
Continued

41
Chapter 6 Bringing High Reliability to the Operating Room
Table 6.2 (continued) World Health Organization top ten human factors topics
for promoting patient safety and tools for them
Human factors topics for
promoting patient safety
Tools and measurements
Team level
Teamwork dynamics
(structure and processes)
Team Climate Assessment Measurement
Team Self Review
Team STEPPS Teamwork Attitudes Questionnaire
Anesthetists’ Nontechnical Skills
Nontechnical Skills for Surgeons
Nontechnical Skills for Theatre Nurses
Observational Teamwork Assessment for Surgery
Oxford NOTECHS
Revised NOTECHS
Team leadership
Situational Leadership
Leadership Opinion Questionnaire
Perceptions of Supervisory Behaviours for Safety
Individual level (cognitive skills)
Situation awareness
Situation Awareness Global Assessment Technique
Situation Awareness Rule of Three
Decision making
Questionnaire for Decision Making Styles
Cognitive Task Analysis
Tactical Decision Games
Individual level (personal resources)
Stress
HSE Stress Indicator Tool
NIOSH Occupational Stress Information and Stress Questionnaire
Fatigue
Fatigue Avoidance Scheduling Tool
Fatigue and Risk Index
Work environment level
Workplace hazards
Root Cause Analysis Toolkit
Root Cause Analysis Framework
Healthcare Failure Mode and Effects Analysis
Failure Mode and Effects Analysis
Fault Tree
Job Hazard Analysis
Probabilistic Risk Assessment
Abbreviations: DASH, Debriefing Assessment for Simulation in Healthcare; DOD, Department of Defense; HSE, health and safety executive; NHS,
National Health Service; NIOSH, National Institute for Occupational Safety and Health; NOTECHS, nontechnical skills; SBAR, Situation, Background,
Assessment, Recommendation; STEPPS, Strategies and Tools to Enhance Performance and Patient Safety.
Source: From Methods and Measures Working Group of WHO Patient Safety. Human Factors in Patient Safety: Review of Topics and Tools. World
Health Organization; 2009.

SECTION II LEGAL AND SAFETY ISSUES
42
to exist in cramped, confined spaces and at the same time
removing any tremor or sudden motions automatically, the
robot has transformed how surgery is performed for proce­
dures such as prostatectomy.
Another effective systems-based approach is through
simplification and standardization. In health care, the adop­
tion of Six Sigma and Lean concepts has been particularly
popular in trying to accomplish these goals. Six Sigma uses
a five-point cycle, (1) define, (2) measure, (3) analyze, (4) im­
prove, and (5) control, to minimize variability (i.e., defects)
to one in a million.45 Lean was initially developed in the Jap­
anese automotive industry to increase productivity through
the elimination of variability, waste, and inflexibility with
rigorous performance management.46 In health care, it has
successfully been implemented in the OR and beyond.46 By
using these established techniques, OR processes can be
streamlined and improved.45,46 Key to both these improve­
ment processes is the aforementioned measurement of key
indicators to demonstrate progress.
The introduction of the improvement management
strategy of Enhanced Recovery After Surgery (ERAS) is an­
other good example of a systems-focused standardization
approach.47 First used in the care processes of colorectal pa­
tients,48 ERAS uses evidence-based practices to replace tra­
ditional care patterns in an attempt to eliminate variability
in care. This strategy takes a global approach to surgical care
through its comprehensive approach, in which all aspects
of care are addressed. Evidence-based principles are used,
starting with preoperative care, extending through intraop­
erative care, and finishing with postoperative care. For ex­
ample, in general surgery, replacing preoperative prolonged
fasting with carbohydrate loading, aggressive measures for
pain control, and early postoperative oral supplementation
and mobility are emphasized. Thus the ERAS conceptual
framework serves as a systems-based attempt to bring con­
sistent, reliable care to the patient, starting with his or her
first visit to the clinic and extending through that individ­
ual’s discharge from the care of the surgeon.49 Compared
with traditional care (i.e., surgeon practices based on train­
ing or preference), ERAS has been shown to reduce met­
abolic stress, maintain fluid homeostasis, improve insulin
sive, they emphasize the importance of measurement to
gauge the effectiveness of any changes attempted. Without
accurate (i.e., valid and reliable) methods of measurement
and assessment, progress cannot be gauged appropriately.
According to HF engineering principles, strategies for
improving OR surgical care include both systems-focused
and people-focused interventions. The Hierarchy of Inter­
vention Effectiveness risk management theory provides a
framework for identifying which ones have the so-called
“biggest bang for the buck”—that is, are the most effective
in their implementation13 (Fig. 6.4).
As mentioned earlier, in general, systems-focused ap­
proaches are more effective than people-focused efforts,
but both are important in attaining the HRO-like function­
ing desired. Thus force functioning, when applicable, is one
of the most useful and effective interventions. An example
of this sort of systems-focused strategy to improve patient
safety was the redesign of the anesthesia machine using the
pin index safety system that has specific pin configurations
for each medical gas used on the machine to prevent mis­
connecting the wrong gas to the wrong line.43 Another ex­
ample is avoiding OR layout and design features that lead to
workflow disruptions.44 Through the use of force function­
ing, personnel are set up to succeed by having only choices
of actions that are familiar and help the patient.
After force functioning, computerization and automa­
tion are two of the more effective systems-focused strate­
gies for improving reliability in an organization. In health
care and the OR, the recent widespread adoption of elec­
tronic health records (EHRs) is the most prominent example
of this type of approach. By making notes and orders leg­
ible, providing practitioners with “best practices” reminders
and suggestions, and allowing the creation of “hard stops”
to ensure critical orders and interventions are performed,
computerized EHRs provide multiple avenues to improve
care and safety.
Although automation may seem difficult to implement
in the health care setting because of the variability of patient
conditions and responses to care, an effective OR example
is the introduction of robotic surgery. By maintaining the
degrees of freedom of the hands available in open surgery
Force functioning
Systems-focused
Degree of effectiveness
People focused
Computerization
Standardization
Automation
Simplification
Checklists
Policies
Training
Double checks
Reminders
Rules
Education
Fig. 6.4 Hierarchy of intervention effec­
tiveness.

43
Chapter 6 Bringing High Reliability to the Operating Room
be used to improve operative management and procedure
performance.
Perhaps the most work to improve care in the OR setting
has centered on improving that combination of cognitive,
social, and personal resources skills known as nontechni­
cal skills (NTS) to promote highly reliable team function.56
As alluded to earlier, such team building is difficult because
of several challenges: different motivations for each profes­
sion, competing pressures related to throughput and safety,
the focus on individual achievement rather than team per­
formance, the existence of rigid hierarchies, and unrealis­
tic expectations.57 People-focused interventions include a
range of strategies that have demonstrated improvements
in both process and outcome measures in the surgical care
of the patient58–71 (Table 6.3). Clearly, the use of checklists,
reminders, and double checks has a benefit.
­sensitivity, and shorten overall recovery.49 In addition, Nich­
olson et al50 have demonstrated in their meta-analysis that it
reduces the risk of complications across a broad spectrum of
surgical procedures (e.g., colorectal, upper gastrointestinal,
joint, genitourinary, thoracic).
Once systems-focused improvements have been suc­
cessfully addressed, people-focused interventions should
be implemented. In the OR, these approaches center on the
knowledge, skills, and attitudes (KSAs) recognized as im­
portant to effective patient care (Fig. 6.5). From the tech­
nical skill-set perspective, training and education using
simulation-based models and national curricula (e.g., Fun­
damentals of Laparoscopic Surgery [FLS],51 Fundamentals of
Endoscopic Surgery [FES],52 Fundamentals of Robotic Sur­
gery [FRS],53 Advanced Trauma Life Support [ATLS],54 and
Advanced Trauma Operative Management [ATOM]55) can
Table 6.3 Representative people-focused interventions using checklists,
briefings, and team training to improve teamwork in the operating room
Group
Intervention
Results
Haynes et al58
WHO checklist
↓ Overall morbidity and mortality
Treadwell et al59 (systematic
review)
Surgical checklists
↑ Detection safety issues, ↑ communication,
↓ complications
Ziewacz et al60, Arriaga et al61
OR crisis checklist
↑ Adherence to critical management steps, life-
saving processes of care
Russ et al62 (systematic review)
Safety checklists
↑ Perceived and observed teamwork (nurses,
anesthesiologists, surgeons)
Awad et al63
Preoperative briefing
↑ Adherence to SSI and DVT prophylaxis
Paige et al64
Preoperative briefing
↑ Teamwork; trend toward ↓ OR time
Hicks et al65 (review)
Preoperative briefings
↑ Communication, compliance to SSI and
DVT prophylaxis, safety climate; ↓ workflow
disruptions
Grogan et al66
Team training
↑ Attitudes toward teamwork
Nontechnical skills
Technical skills
Endotracheal intubation
Knot tying
Cognitive skills
Problem solving
Analytical thinking
Interpersonal skills
Communication
Assertiveness
Fig. 6.5 People-focused
interventions.
Continued

SECTION II LEGAL AND SAFETY ISSUES
44
Rules and policies have also been implemented to cre­
ate procedural constraints that promote patient safety and
improve surgical care. The most well-known of these sorts of
policies is the Joint Commission’s requirement of the use of
The Universal Protocol for Preventing Wrong Site, Wrong Pro­
cedure, and Wrong Person Surgery in their accredited hospi­
tals.72 Local policies and procedures related to how technol­
ogy such as laser surgery is used are other examples.
Training and education form the bulk of people-focused
interventions related to improving team function and OR re­
liability. Such training can take on a variety of modalities: in­
formation-based (e.g., didactics), demonstration-based (e.g.,
videos, role-play), and practice-based (e.g., simulation-based
techniques).56,73 Whatever modality is chosen, a blended ap­
proach using an established NTS framework that adheres to
a well-developed curriculum with adequately trained fac­
ulty is essential for success.56 Employing interprofessional
education (i.e., two or more professions coming together to
learn from, with, and about each other) is also beneficial
and, in fact, has been shown to improve collaborative team
behavior in the OR.74
Simulation-based training (SBT) is particularly well
suited to OR and surgical team training, because it creates
a realistic, yet safe learning event in which the therapy for
rare but life-threatening conditions and situations can be
rehearsed without any harm to patients and in which the
consequences of mistakes can be revealed. In addition, it is a
particularly effective modality for training residents and stu­
dents to introduce them to concepts of effective teamwork
and so inculcate team-based KSAs that are beneficial for sur­
gical patient care75–81 (Table 6.4). At LSU Health New Orleans,
we have taken this “get them young” approach and have suc­
cessfully instituted interprofessional simulation-based train­
ing at both the resident and student level with improvements
in team-based attitudes and behaviors that are retained over
a 6-month period.76,77,80,82 Such training is housed within a
comprehensive quality and patient safety framework of team
training targeting the perioperative microsystem.
Application in the Plastic
Surgery Setting
How might HF engineering principles be applied to the plas­
tic surgical care setting? Encouragingly, examples of their
successful application already exist. Of these, the most il­
lustrative is the work of Lee et al83 in developing an intra­
operative pathway for deep inferior epigastric perforator
(DIEP) flap breast reconstruction. This group endeavored to
improve efficiency and outcomes in the DIEP procedures by
first standardizing care throughout the entire process. In this
manner, all instrumentation and the sets of the procedure
were the same for all the surgeons performing the proce­
dure, and perioperative care pathways were streamlined.
Although useful, these strategies did not result in the desired
improvements. They then applied a variation of a Harvard
Business School model involving “relational coordination”
teamwork that has been successfully used in other high-reli­
ability industries (i.e., aviation) to the procedure. In this man­
ner, the complex operation was divided into distinct phases
in which the needed personnel, expertise, instruments, sup­
plies, equipment, and expected duration where delineated.
“No hand-off zones” were created during high-risk phases of
the procedure in which breaks were off limits. In addition,
set break periods were also instituted for each profession
during phases in which responsibilities and workload per­
mitted it. Benchmarks were established for completing each
phase and processes established to discuss variances. Finally,
antibiotic redosing schedules were established at set times
in the procedure. This systems-focused approach resulted in
decreases in operative times and costs and improvement in
staff perceptions of teamwork and communication.
Table 6.3 (continued) Representative people-focused interventions using checklists,
briefings, and team training to improve teamwork in the operating room
Group
Intervention
Results
Armour Forse et al67
Team training (Team STEPPS)
↑ On time first start; ↓ overall morbidity and
mortality
Nurok et al68
Team training
↑ Communication and team skills; ↑ threat-to-
outcome scores
Robertson et al69
Team training and Lean
↑ WHO checklist compliance, teamwork; ↓ glitch
rate
Hicks et al65 (review)
Team training
↓ Overall morbidity and mortality, intraoperative
adverse events
Doumouras et al71 (review)
Simulation-based training
↑ Team-based skills; no decay (2 months)
Hull L et al70 (review)
Simulation-based training
Failure NTS leading to ↑ technical errors
Abbreviations: DVT, Deep vein thrombosis; NTS, nontechnical skills; OR, operating room; SSI, surgical site infection; STEPPS, Strategies and Tools to
Enhance Performance and Patient Safety; WHO, World Health Organization.

45
Chapter 6 Bringing High Reliability to the Operating Room
Conclusion
Because of their complex, dynamic natures, the OR and its
associated perioperative microsystem are clinical settings
in which high reliability is needed to provide safe, effec­
tive surgical care. Such environments, however, don’t just
become “safe.” Instead, they must function in an HRO-like
manner in which mindful preparation and practice trump
mindless “going through the motions.” To achieve this state,
the work culture must embrace performance-based prin­
ciples in which a preoccupation with failure and sensitiv­
ity to operations lead to a commitment to resilience in an
ever-changing, high-risk work environment. Such a goal is
best achieved through the application of HF principles and
engineering designed to create defenses-in-depth through
systems-focused and people-focused interventions. In this
manner, surgical care can be made more reliable, effective,
and safe.
A more recent example of the use of HF engineering
strategies to improve plastic surgical care is the application
by Batdorf et al84 of an ERAS pathway to DIEP flap microvas­
cular breast reconstruction. Using a multidisciplinary team,
they developed a comprehensive ERAS protocol for this pro­
cedure and compared its effectiveness to the traditional care
pathway. Implementation resulted in a decrease in their pri­
mary end point of hospital length of stay. In addition, it re­
sulted in a decrease in opioid requirements. No difference
was seen in complication rates.
In addition to these examples of systems-focused strate­
gies, people-focused approaches to improving plastic surgi­
cal care have been advocated. They include simulation-based
training of technical85 and nontechnical skills86,87 and the use
of standardized patients to teach and evaluate plastic sur­
gery residents in the core competencies.88 In this manner,
staff and plastic surgeons have the opportunity to obtain
the necessary KSAs needed to perform effectively in the OR
and perioperative surgical setting.
Table 6.4 Examples of the benefits of simulation-based team training in
surgical care involving residents or students
Group
Intervention
Result
Nguyen et al75
Simulation-based training (lap CCY) involving
residents
Improved completion of preoperative checklist
and intraoperative ACGME competencies
Paige et al76,77
Simulation-based on-site training (in situ) of
staff and residents
Improved attitudes toward team-based
competencies reinforced with distributed
training
Pucher et al78
Simulation-based training (ward rounds)
involving residents
Feasibility demonstrated
Stefanidis et al79
Simulation-based training involving residents
and nursing students
Resident preference for nursing staff over
students
Nicksa et al80
Simulation-based training off-site, center-
based training (ex cura) (high-risk scenario)
of residents
PGY 2 improvement in NTS; no change in PGY 1
Paige et al81
Simulation-based training ex cura of
interprofessional student teams
Improved attitudes toward team-based
competencies; improvement in individual and
team-based behaviors
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; lap CCY, laparoscopic cholecystectomy; NTS, nontechnical skills; PGY,
postgraduate year.
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SECTION II LEGAL AND SAFETY ISSUES
48
Plast Reconstr Surg 2009;123(2):729–738, discussion
739–740
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plastic surgery training and education: the path forward.

49
At one time, plastic surgeons were at a minimal risk for
malpractice actions, because potential plaintiffs often were
ashamed to admit that they had undergone a cosmetic pro­
cedure. With increased popularity of cosmetic procedures,
any stigma has vanished, as has patients’ reluctance to file
both regulatory and civil complaints, and plastic surgery in
is now one of the highest-risk medical specialties for medi­
cal malpractice claims.1
Therefore preventing claims based upon unfavorable re­
sults and effectively managing the legal ramifications are
both essential in today’s practice of plastic surgery. From a
prevention standpoint, good clinical care alone cannot guar­
antee a “favorable result,” and the surgeon must strive to
manage the patient’s expectations before the actual proce­
dure. Once the patient deems a result to be “unfavorable,”
however, the surgeon must also be prepared to mitigate the
legal risks associated with such a result.
Primer on Liability for Medical
Malpractice
Liability for medical malpractice, which, in the case of a
plastic surgeon, is almost always predicated upon an unfa­
vorable result, can be both civil and regulatory.
A civil suit must satisfy four key points to succeed2:
1. A duty of the defendant
2. A breach of that duty
3. The breach being the proximate cause of damages
4. Those damages being compensable by money
In the regulatory arena, only the first two items theoreti­
cally are at issue. In other words, regulators will only de­
termine whether the surgeon had a duty (such as a rule or
an acknowledged standard of care) and breached that duty.
At least theoretically, licensing officials are not concerned
with the damage that may have been caused, because the
duty of licensing bodies is to ensure that future patients
are protected; therefore the damage caused by a breach of
a medical duty will alone be seen as cause for sanctions.
The common thread in both type of actions is whether
the surgeon had a legal duty and whether that duty was
breached. When a patient has an unfavorable result, the ex­
istence of damages is assumed, and the central legal issue
becomes whether the surgeon breached a duty to the pa­
tient. This duty may emanate from a multitude of sources,
such as explicit laws, a standard of care accepted within the
medical community, or a duty implicitly or explicitly cre­
ated by the surgeon.
Avoiding Unfavorable Results
and Complications
From a legal perspective, the physician’s duty is to uphold
both the standard of care and any duty that the physician
implicitly or explicitly accepts. The standard of care, which
usually is outside the control of an individual physician, is
a product not only of the general consensus of the medical
community, but also of laws that may be passed by legisla­
tures and regulatory boards.
Other duties, however, are implicitly or explicitly ac­
cepted by the physician through the use of warranties that
are often inadvertently made in advertisements and during
preoperative consultations. Fortunately, the expectations
that create these duties often may be managed effectively
through careful craftsmanship of marketing materials and
The Legal Implications of
Unfavorable Results
Christopher L. Nuland
CHAPTER
7

SECTION II LEGAL AND SAFETY ISSUES
50
or regulated office surgery facilities must always comply
with the laws governing such practice parameters regard­
ing the types of surgeries that may be performed in each set­
ting, the medications that must be available, and what other
professionals must assist in the procedure.7 Each of these
legal requirements constitutes a separate and distinct stan­
dard of care, and compliance with such laws is essential, be­
cause any breach of the legal requirements is automatically
deemed to be a breach of one’s duty. Coupled with the pa­
tient’s perception of an unfavorable result, a technical breach
of a rule or statute creates a breach of an acknowledged duty
and damages, with the only remaining issue being whether
the breach was the proximate cause of the damage.
Warranties
Although the plastic surgeon cannot alter most of the as­
pects of the standard of care, because such standards are
the product of lawmakers and the overall medical commu­
nity, he or she can minimize any owed duty by limiting or
eliminating the use of warranties. Very few plastic surgeons
would knowingly create an extraordinary duty by provid­
ing en express, a written guarantee; however, many of the
actions of the surgeon and his or her staff can unknowingly
create an implied warranty that creates the underlying duty
in excess of that imposed by the medical community or stat­
ute. In fact, such implied guarantees have been recognized
as creating the requisite duty of care for at least 2 centuries
and often impose additional duties upon the plastic sur­
geon.3
Such implied warranties may be created from the mo­
ment that a patient becomes aware of the plastic surgeon’s
availability through a seemingly innocuous advertisement.
From a marketing perspective, advertisements must im­
ply dramatic results to be effective; from a legal perspec­
tive, however, such advertisements may create unrealistic
expectations and an implied warranty that a prospective
patient will obtain an unrealistic result. With that implied
warranty of spectacular results becomes a duty, and what
might normally be deemed a satisfactory result is deemed
by the patient not to meet the expectations produced by
the advertisement. The patient therefore views the clini­
cally acceptable result as “unfavorable” and has reason to
claim that the physician has breached the duty to produce
a specific result.
Advertisements that run afoul of this concept can also
create regulatory liability, because advertisements that cre­
ate unreasonable expectations are actually prohibited in
many jurisdictions. The State of Florida, for instance, pro­
hibits advertising that “Creates false or unjustified expecta­
tions of beneficial assistance.”8
The risk of an implied warranty continues through the
consultation, for which many plastic surgeons employ sales­
people to obtain patient commitments for multiple or en­
hanced procedures. Again, although professional marketing
can yield increased profits, overzealous marketing can create
responsible use of the consultation and informed consent
processes.
Standard of Care
For centuries the common law of England and the United
States has recognized that a physician has a duty to provide
services in a competent manner.3 Moreover, in virtually ev­
ery Western jurisdiction, legislative bodies have codified
into law that the surgeon has both a civil and regulatory ob­
ligation to meet the prevailing standard of care (for exam­
ple, see Florida Statutes §458.331[1][t] and §766.102[1]),
with the following being a fairly common definition of the
standard of care4,5:
The prevailing professional standard of care shall be that
level of care, skill, and treatment which, in light of all rel­
evant surrounding circumstances, is recognized as accept­
able and appropriate by reasonably prudent similar health
care providers.4
As every practicing physician understands, however, an
unfavorable result does not necessarily constitute a breach
of the standard of care, and lawmakers fortunately have
codified that reality.6
Regulatory boards composed of physicians also routinely
understand this, although laypeople often expect optimum
results from every medical intervention and often believe
that they are entitled to compensation for unfavorable re­
sults, even when such results are unrelated to the quality
of the physician’s care. Although the plastic surgeon can, to
some extent, define his or her own standard of care by care­
fully indicating to the patient what the surgeon will and will
not do and what the patient may expect (discussed later),
ultimately the standard of care is a combination of rule and
statute on the one hand, and the consensus of the medi­
cal community in which the surgeon operates on the other.
Defining the standard of care within a medical com­
munity is admittedly challenging. Depending on the needs
of the patient and the training and preferences of the phy­
sician, different techniques and procedures may be used.
For instance, liposuction may be either tumescent or tradi­
tional and breast implants may be either saline or silicone,
and defining a single standard of care applicable to all pa­
tients in all settings becomes problematic, at best. There­
fore both civil and legal actions based upon a surgeon’s al­
leged breach of the community standard of care inevitably
become a battle of competing expert witnesses, with each
side employing members of the health care community to
argue that the physician either did or did not uphold the
standard of care.
Although the standard of care within the medical com­
munity is constantly evolving and amorphous, rules and
statutes are generally fairly exact in the duties that they im­
pose upon the physician. For instance, those working in spe­
cific settings such as hospitals, ambulatory surgery centers,

51
Chapter 7 The Legal Implications of Unfavorable Results
with which the patient is displeased. Although the natural
tendency is for the surgeon to become defensive, the post­
surgical interaction with the patient is perhaps the most
important opportunity to address the patient’s concerns
and minimize the chances of a formal complaint.
Dealing with a dissatisfied patient requires a constant
balancing of competing interests. On the one hand, the sur­
geon always desires to ensure that the patient is happy with
the experience and that the surgeon displays empathy for
the patient’s plight; on the other hand, the physician must
ensure that the tools at his or her disposal, such as refunds
and revision procedures, are used sparingly so as to neither
concede that the original procedure was performed inad­
equately or risk the financial solvency of the practice by en­
gaging in an unsustainable amount of uncompensated care.
Finally, the physician must be cognizant of the fact that
many patients will never be happy and will continually place
emotional and financial pressure on the practice. In these
cases, dismissal of the patient and the retention of qualified
counsel are essential to protect the surgeon.
Empathy without Admission
Although it is important to acknowledge the patient’s dis­
pleasure, the surgeon should never admit to being person­
ally dissatisfied with the results, because such an admission
can be used against the physician at a later date. Although
there is a growing trend toward allowing a physician to say
“I am sorry” without admitting guilt, such rational laws are
by no means universal.11 If the result is one of which the
patient was made aware before the procedure, the patient
should be gently reminded of this, and the physician should
document that reminder. If the result was one for which
the patient was unprepared, then the surgeon should stress
that such results are not abnormal, but also develop a plan
(with the patient) for obtaining an optimum result under
the circumstances.
If, however, the suboptimum result has left the patient
with a worrisome degree of dissatisfaction, the surgeon may
want to address that patient’s concerns by offering a refund
or a revision procedure.
Refunds
Refunds can ease a patient’s concern that the physician
overcharged for the procedure and the suboptimum result,
but such refunds can also create legal risks. A refund creates
a presumption that a contract was left unfulfilled because
the physician did not provide the full service for which the
patient contracted when he or she agreed to undergo a pro­
cedure. Obviously, such an admission could later be used
against the physician to demonstrate that the surgeon failed
to fulfill a contractual duty, and that breach of a contractual
duty could give rise to a civil or administrative action at a
later date. Therefore “money-back guarantees” should be
avoided universally.
unrealistic expectations that rise to the level of an implied
warranty. Under the legal doctrine of respondeat superior,
the surgeon that employed the marketer is responsible for
the claims and promises made by such an individual, and
it is for this reason that the surgeon must not only approve
any and all promotions, but must always remain vigilant in
ensuring that members of the staff do not make promises
that the surgeon may not be able to fulfill.
Managing Expectations
In each of the previously mentioned cases, the key compo­
nent of a legal risk management strategy is for the surgeon
to manage the patient’s expectations, from the patient’s
first impression through the postsurgical period. Although
the patient’s expectations must admittedly be high enough
to entice the patient to have an elective procedure, the plas­
tic surgeon’s office must balance that marketing need with
realistic goals that will encourage the patient ultimately to
view a procedure’s results as “favorable.”
For instance, advertisements should include disclaimers
stating that individual results will vary, and that no guaran­
tee of outcomes can be made, especially when the advertise­
ments use professional models or patients who have been
fortunate enough to experience extraordinary results. Such
advertisements also should not include outrageous claims of
beneficial results; without such claims, the patient’s expec­
tation is lowered. This management of expectations should
extend to consultation, where patients should be provided
written, realistic explanations of offered procedures, and
marketing staff should be instructed, to manage (again, in
writing) the patient’s expectations. The existence of written
materials serves to protect the surgeon, because a dispute as
to what was communicated orally often may be adjudicated
by the unequivocal and undisputed document that was pro­
vided to the patient.
The surgeon’s ultimate opportunity to manage expecta­
tions is through the informed consent process. This is where
the surgeon explains the procedure and its likely benefits
and, more important from a legal perspective, explains and
documents the possible risks and the “medically acceptable
alternative procedures and treatments.”9 This documenta­
tion is essential should a result not be optimum, because
the physician may defend the outcome by demonstrating
that the patient was fully aware of the risks and alternatives
and that the physician breached no duty by performing pro­
cedures that produced results consistent with an informed
consent signed by the patient. However, no informed con­
sent is foolproof, and patients generally cannot waive their
rights to sue for medical malpractice.10
Managing an Unfavorable Result
No matter how well the plastic surgeon manages the pa­
tient’s expectations or documents the risks, however, in­
evitably some procedures will yield unfavorable results

SECTION II LEGAL AND SAFETY ISSUES
52
Finally, although discharging the patient will not release
the physician from any liability incurred through the date of
the discharge, it can prevent future liability from accruing.
When to Seek Legal Guidance
Just as an attorney would be unwise to perform plastic sur­
gery, a physician likewise should be wary of practicing law,
especially when the surgeon’s license and reputation are at
stake.
Lawyers and risk managers should be an integral part of
the surgeon’s team. An attorney can evaluate advertisements
for potential pitfalls and help draft informed consents that
will help protect the physician in the event of an unfavorable
result. Likewise, health care risk managers should be en­
gaged to assist in the drafting of policies and procedures that
not only comply with local laws, but also minimize the likeli­
hood of an adverse outcome (such policies and procedures
are also essential to the defense of a malpractice claim).
In the event of an adverse event (which may or may not
have been caused by a medical error), both the risk manager
and attorney should be contacted promptly. Together, the at­
torney and risk manager will evaluate the circumstances of
the event and, if necessary, revise policies and procedures
to minimize the chances of future adverse events (in most
jurisdictions, consultations with an attorney are protected
by the “attorney-client privilege,” meaning that the contents
of any such consultations are immune from discovery by
regulators and potential claimants).12 These professionals
also will work together to ensure that all documentation is
preserved and that any legally mandated reports are drafted
in such a manner as to protect the medical practice to the
greatest extent possible and to avoid incriminating the sur­
geon.
Conclusion
Absent an indefensible act of malpractice, a patient’s de­
termination that a procedure yielded an unfavorable result
usually may be prevented by managing the expectations of
the patient. Such management must occur through respon­
sible advertising, strict adherence to applicable laws, honest
and documented consultations, and a thorough informed
consent practice, all of which should be coordinated with
a team that includes legal counsel and experienced health
care risk managers.
Even when these precautions are taken, however, pa­
tients often will remain dissatisfied with the results, at
which point it is incumbent upon the surgeon to limit his
or her own exposure by not admitting to any flaw in the
performance of a surgical duty, simultaneously placating the
patient, and teaming with outside professionals to both miti­
gate any damage and prevent future misadventures.
If a refund is to be given, it should be accompanied by a
release in which the patient releases the practice, the sur­
geon, the staff, and all affiliated providers from and against
any and all claims associated with the procedure. Only in this
way may the surgeon protect all involved from further action.
Revision Procedures
An unfavorable result often can be improved upon by a
subsequent procedure. Ideally, the possible need for such a
revision should be discussed in advance by the patient and
surgeon, in which case the subsequent procedure should
be treated as an expected component of the patient’s plan
of care.
If such a follow-up procedure has not been discussed
previously, however, several other issues emerge, such as
whether the patient should pay for such a procedure and
whether the performance of such a procedure is tantamount
to an admission that the first procedure was not performed
correctly. From a legal perspective, it is imperative that the
surgeon in no way indicate that the necessity of a revision
was caused by any defect in the performance of the first
procedure; to do so is not only an admission that a duty
was breached, but also that the breach caused the need for
a second procedure (which has a monetary value). In other
words, performing a revision procedure to correct a “mis­
take” during the first procedure satisfies every element of a
successful malpractice claim.
A free procedure may be deemed as an admission that
a mistake was made during the initial operation, whereas
a charged procedure could alienate an already dissatisfied
patient. These interests must be balanced carefully to de­
termine a price point that will both protect the surgeon
and satisfy the patient. Any unplanned revision procedure
should be accompanied by a release similar to the one that
would accompany a refund.
Dismissing the Patient
Unfortunately, occasions exist when a dissatisfied patient
cannot be placated either by a refund or a subsequent pro­
cedure. In such an event, the surgeon may be placed in the
uncomfortable position of deciding that there is nothing
more that can be done for the patient. In such an instance,
the surgeon may want to affirmatively dismiss the patient
to prevent a misunderstanding that the relationship has
been severed and that the physician has no further respon­
sibility for the patient’s care. If a patient is to be dismissed,
however, the surgeon should ensure that the dismissal is
not abrupt, because such discharges could lead to a claim of
“abandonment.” Rather the physician should offer to con­
tinue to see the patient for emergency care for a limited
period of time (e.g., 30 days).

53
Chapter 7 The Legal Implications of Unfavorable Results
7. Florida Administrative Code 64B8–9.009 Vol. 42/89
(2016)
8. Florida Administrative Code, Advertising, 64B8–11.001(2)
(c). Final March 2, 2015
9. §766.103 Fla Stat (2015)
10. Tunki v. Regents of the University of California, 383 P.2nd
441 (Cal, 1963)
11. Amori G. Disclosure of Unanticipated Events in 2013. Chica­
go: American Society of Healthcare Risk Management; 2013
12. § 90.502 Fla Stat (2015)
References
1. Jena AB, Seabury S, Lakdawalla D, Chandra A. Malprac­
tice risk according to physician specialty. N Engl J Med
2011;365(7):629–636
2. Prosser WL, Keeton WP, Dobbs DB, Keeton RE, Owen DG,
eds. Prosser and Keeton on Torts. 5th ed. St. Paul, MN:
West Publishing Co; 1984
3. Blackston W. Commentaries on the Laws of England. Ox­
ford: England, Clarendon Press; 1765–1769
4. §766.102(1) Fla Stat (2015)
5. §458.331(1)(t) Fla Stat (2015)
6. §766.102(3)(b) Fla Stat (2015)

Medical negligence cases in general are being filed far less
often than they were 20 years ago. In my home state of Il­
linois, for example, filings since 2002 have dropped more
than 40%, according to the Cook County Jury Verdict Re­
porter and the Daily Law Bulletin, which track filings and
outcomes.1 Medical negligence actions cannot even be filed
in Illinois and many other jurisdictions unless the case has
been reviewed and certified as meritorious by a physician
licensed in the same school of medicine as the defendant.2
Multiple studies published in the last few years indi­
cate that fewer than 10% of the victims of malpractice ever
contact a lawyer.3,4 It is in this context that cosmetic sur­
gery cases must be viewed. The reality is that cosmetic
surgery cases are often the “last player chosen” by plain­
tiff’s attorneys practicing in the medical negligence area
of the law.
There are many reasons for this, including the following:
1. The elements of proof
2. Jurors’ bias
3. Public perception
The Elements of Proof
In medical negligence cases, the plaintiff has the burden of
proving that the defendant physician was negligent. To do
this, a plaintiff must do three things:
1. Establish the standard of care in the medical commu­
nity by which the defendant physician’s treatment is
measured
2. Prove that the physician deviated from that standard of
care
3. Prove that the resulting injury was proximately caused
by the physician’s deviation
To prove that a defendant physician deviated from the
standard of care, the plaintiff must present evidence that
the physician failed to possess and apply that degree of skill
and care that a reasonably careful physician would apply
under similar circumstances. This, by its very nature, is a
subjective standard, and jurors are instructed that they can
only make their determination as to whether the standard
has been violated based on expert testimony. In addition,
the plaintiff has the burden of proving that the negligent
act or acts were a cause of the damage suffered. In cosmetic
surgery cases, the defense often frames the procedure as
involving “as much art as science,” and the subjectivity be­
comes that much stronger. To prevail, the defense need only
demonstrate that the procedure in question requires the ex­
ercise of professional judgment and that there are, in fact,
well-qualified cosmetic surgeons who, under the same cir­
cumstance, would have acted in the same manner as the de­
fendant. The law does not impose on physicians the burden
of being right all the time or being free from complications
or bad outcomes. The law only requires the physician act
reasonably, and that standard is determined by what other
qualified, careful physicians would do.
In short, cosmetic surgery cases are tailor-made for the
defense bar. They involve lots of subjective judgment. What
may appear to a qualified physician to be an excellent result
may, in “the eye of the beholder” (the patient), be an unsatis­
factory one. By the definitions and instructions given by the
court to the jurors, that scenario does not equal malpractice,
and the overwhelming likelihood is a jury will rule in favor
of the defendant.
Jurors’ Bias
In my 34 years trying medical cases on behalf of both care
providers and patients, I have perceived an inherent bias
that jurors have against patients who undergo surgery for
Medical Malpractice and Plastic Surgery
David R. “Chip” Barry, Jr.
CHAPTER
8
54

55
Chapter 8 Medical Malpractice and Plastic Surgery
wounds. After skin grafting, the plaintiff developed substan­
tial knotlike scar tissue behind both nipples. The defendant
recommended that the plaintiff consult a different surgeon.
The plaintiff followed the defendant’s advice, and another
surgeon performed multiple corrective surgeries, including
breast reconstruction with implants.
In her lawsuit, the plaintiff alleged that the defendant
incorrectly marked her breasts for the reduction surgery and
removed too much breast tissue, which caused tension at the
surgical site and a reduction of blood flow. The defendant
claimed that the plaintiff had an old scar on her right breast
that complicated the procedure and that wound dehiscence
and fat necrosis formation were common complications of
the procedure. The jury returned in favor of the plaintiff.6
In Mastopexy and Breast Reduction: Principles and Prac­
tice, Dr. Melvin A. Shiffman7 observed that complications
like those experienced by the Roanoke City plaintiff almost
always result in litigation. Specifically, he noted, “Juries tend
to be swayed by the severity of the injuries and the need for
multiple corrective surgeries rather than seriously consid­
ering whether there was a breach of the standard of care.”
Unkept Promises
Another type of case plaintiff attorneys may find appealing
is one in which promises were explicitly made but not kept.
Advertisements offering services at a discount if multiple
procedures are purchased can lead to the perception that
the physician is not, in fact, a medical professional, but a
salesman who is more interested in maximizing profit than
providing quality medical care. Consequently, promotional
materials used by the doctor to obtain patients can serve as
the basis for a lawsuit and often become a focal point of dis­
covery during litigation. Websites and advertising, likewise,
can contain statements that put a defendant physician in an
untenable position as he or she attempts to explain that a
complication is responsible for an unexpected result. Pro­
motional materials seldom detail complications and unsat­
isfactory results.
In a legal journal article entitled “Medical Malpractice—
Reduction Mammoplasty,” John Herbert Tovey8 writes his
advice to plaintiff’s attorneys regarding how they should
conduct an initial interview with a potential client who
may have been injured by cosmetic surgery. Tovey tells at­
torneys that, in plastic surgery, “a physician may speak with
less care” when addressing specific diagnoses or guarantees.
He notes,
Statements that a procedure will result in undetectable
hairline scars are not unknown. Preceding an operation in­
volving the female breast, a practitioner sometimes shows
the patient photographs of other women to determine from
the patient the contour of breast she would like; the client
should always be pressed for the exact wording of conversa­
tions covering the anticipated result of any surgery. Counsel
should also learn exactly how the client came to consult the
cosmetic reasons. The prevailing sentiment is the patient,
who electively undergoes a procedure, intended to change
some attribute given to the patient by God or Mother Na­
ture, and assumes the risk if things should go awry. The
blame for the unsatisfactory result lies with the patient
rather than the doctor who, in point of fact, may have been
less than careful during the procedure.
Medical negligence cases as a whole are difficult for
plaintiffs to win (in Cook County, Illinois, the defense wins
70 to 80% of the time in all medical cases tried to verdict).5
This additional hurdle to overcome renders cosmetic cases
singularly unattractive for any plaintiff.
Public Perception
Popular culture, through television shows such as Extreme
Makeover, has created the impression that many cosmetic
procedures are not really medical services at all, but are
more akin to a manicure, pedicure, and stylish haircut. This
perception makes it less likely the average juror will find
against a physician on a claim that impugns his or her pro­
fessional competence.
Although cosmetic surgery is but one component of
plastic surgery, cosmetic surgery cases, despite the chal­
lenges they face in the legal arena, comprise the vast ma­
jority of the plastic surgery calls my firm receives from po­
tential clients. Although we decline to accept professional
responsibility in more than 95% of those potential cases,
there are a few categories that generate greater interest on
our part than others.
Multiple Procedures
Cases that involve multiple procedures of the same kind
by one doctor on a patient raise a red flag. If a patient has
undergone multiple cosmetic breast procedures within a
few years or multiple facelifts in a similar time period, the
advice the surgeon is giving the patient or the failure to
temper unrealistic expectations may lead to closer scrutiny
by the patient and, ultimately, plaintiff’s counsel for a pos­
sible lawsuit.
In 2005, a Roanoke City, Virginia, jury awarded a plain­
tiff a $1.5 million verdict for complications resulting from
a breast reduction surgery.6 The plaintiff, a 60-year-old,
250-pound woman with a breast size of 46DD, agreed to
undergo breast reduction at the suggestion of her plas­
tic surgeon. The defendant, in this case the plastic sur­
geon, removed 1,401/1,500 grams of left breast tissue and
1,044/1,100 grams of right breast tissue. After surgery, the
plaintiff experienced wound dehiscence around her right
nipple and in the inframammary incisions on both breasts.
The plaintiff returned to the defendant to have her breasts
resutured. Shortly thereafter, the new sutures tore through
her right breast, and the plaintiff experienced more wound
dehiscence in her left breast. The defendant then performed
skin grafting, free of charge, to close the plaintiff’s existing

SECTION II LEGAL AND SAFETY ISSUES
56
went awry.10 Hoping to even out the appearance of her
breasts after a lumpectomy, chemotherapy, and radiation,
the plaintiff underwent three different surgeries that left
her with a “gaping wound under her left breast, a grossly de­
formed left breast and significant asymmetry in her breasts.”
The plaintiff required two additional surgeries by another
surgeon.
A key element of the plaintiff’s case was evidence that
her surgeon had understated the risks of a bad outcome.
The plaintiff testified that the surgeon had stated the risk
of serious complication was 1 to 2%, but expert testimony
at trial suggested that the risk, in relation to her radiation
treatments, was as high as 50%.10
Similarly, a Florida jury awarded $825 million (later re­
duced by the court to $2 million) to a woman who, after be­
ing told by her surgeon that he could perform breast implant
and breast lift surgeries during the same procedure, required
13 corrective surgeries.11 The plastic surgeon had failed to
advise the patient of the risks attendant to doing both pro­
cedures in one operation.
The lesson for any plastic surgeon is that discussions
regarding potential complications or unfavorable outcomes
must take place and should be reflected in the medical chart
and, if possible, be made part of the consent form signed by
the patient preoperatively.
The importance of the preoperative informed con­
sent form is highlighted by a $60 million verdict returned
by a Bronx County, New York, jury in January of 2009 (the
trial court reduced the verdict to $4 million, and later, the
New York Appellate Court further reduced the award to
$600,000).12
The plaintiff, a 38-year-old woman, underwent gastric
bypass surgery, reducing her weight from 380 pounds to 180
pounds. As a result of her rapid weight loss, the plaintiff had
substantial amounts of excess skin on her abdomen, but­
tocks, and thighs. The plaintiff consulted several surgeons
about skin removal procedures. In 2003 the plaintiff rejected
a full body lift because it was too invasive. She similarly re­
jected a medial thigh lift because the side effects of vaginal
widening and labial stretching concerned her. In 2005 the
plaintiff consulted the defendant surgeon, who indicated
that he would perform a lateral thigh lift. The plaintiff al­
leged that the defendant advised he would make incisions
on the outside of her thighs, eliminating the risks of vagi­
nal widening and labial flattening, commonly incidental to
a medial thigh lift.12
During surgery, the defendant performed a medial thigh
lift instead of the previously discussed lateral thigh lift. The
defendant’s operative record indicated that the defendant
believed a medial thigh lift was necessary because of the
“tremendous amount of excess skin.” The medial thigh lift
left the plaintiff with labial majora flattening and wound
breakdown scarring. The defendant disputed the plaintiff’s
claim and reported that he did, in fact, tell the plaintiff he
may have to perform a medial thigh lift to remove excess
skin from her inner thighs. However, the defendant’s preop­
defendant surgeon, such as by referral from another physi­
cian or in response to an advertisement.
Physicians must be conscientious about setting the bar on
expectations too high, because the failure to meet them can
result not only in a negligence case, but also, in certain ju­
risdictions, a breach of contract action.
Informed Consent
A predominant issue in all medical negligence cases, but
especially cosmetic surgery cases, is the issue of whether a
plaintiff (patient) has sufficiently given informed consent.
Expectations can be very important, particularly if the doc­
tor advertises great results, so the physician should avoid
making representations that a procedure is “simple” or
“easy” when the possibility exists that it could become more
complicated or require more than one surgery. When it is
represented to the patient that a procedure does not war­
rant any particular concern, and complications subsequently
develop, a legal question as to whether adequate informed
consent was obtained is presented.
An injured plaintiff testifying before the jury that the
defendant did not give him or her any information regarding
the complication that resulted leads to a sympathetic reac­
tion in jurors who consider what they would have thought
if given the same information.
To fully understand informed consent, it is necessary to
review how courts instruct juries on the issue. Tradition­
ally, informed consent was measured by the “professional
standard” rule.9 Under this rule, the plaintiff was required
to establish the following:
1. The general standard of care by physicians in the defen­
dant’s field of practice, under similar circumstances
2. That the defendant deviated from that standard in
obtaining informed consent from the plaintiff
The professional standard rule reflected the belief that
holding a physician to a lay standard of disclosure would
interfere with the flexibility a physician must have in de­
termining what treatment would best meet the patient’s
needs. To prove a case under this rule, a plaintiff was gen­
erally required to present expert testimony to establish the
standard of care and the deviation therefrom.
Recently, however, many jurisdictions have shifted the
focus of their informed consent analysis from the physicians’
perspective to the patients’ perspective. Under more recent
“patient-centered” standards, courts determine the suffi­
ciency of informed consent by measuring the facts of a case
against what a reasonable patient would need to know to
make an informed and intelligent decision. Significant ver­
dicts have been awarded to plaintiffs in cases in which the
risks of a procedure were understated by the physician.
In New York, a breast cancer survivor was awarded $1.1
million when breast augmentation surgery after radiation

57
Chapter 8 Medical Malpractice and Plastic Surgery
­compensation. The patient would also be told what steps
were being taken to prevent similar occurrences in the fu­
ture, while expressing sincere regret that this had happened
at all.13
This policy should hardly have proven as revolutionary
as it turned out to be. Ethical standard promulgated by the
American College of Physicians and the American Medical
Association oblige disclosure of errors, and the Joint Com­
mission on the Accreditation of Hospital Organizations re­
quires disclosure to patients of unanticipated outcomes.14
Instituting a policy with an apology at its forefront re­
sulted in a decrease of open claims at Michigan from 262 in
2001 to 83 in 2009.13 Those numbers have remained steady
in the years since. Thus, although apologies do not guaran­
tee a claim will be avoided, it certainly reduces the likeli­
hood.
Conclusion
My experience is that patients most often like and respect
their doctors and want to believe in them. When those feel­
ings are treated with respect and honesty, they seldom go
away.
Acknowlegment
The author would like to thank Andrew P. Stevens, Attor­
ney, for his contribution to this chapter.
erative notes merely reflected that the patient “wants thigh
lift” and “needs T-type skin excision” and “understands that
skin will stretch and may meloid.” In addition, the consent
form that the plaintiff signed did not mention a medial thigh
lift, vaginal widening, or labial distortion.12
Although the verdict was later reduced by the courts to
$600,000, the jury’s initial $60 million verdict demonstrates
how seriously juries take into account a deficient preopera­
tive informed consent form.12
All of these cases should demonstrate to the thoughtful
plastic surgeon that there is no substitute for common sense,
honesty, and good bedside manner. Patients understand that
complications can occur even in the face of reasonable care.
Being forthright and honest with patients, in my experience,
is the best way to prevent litigation. My observations have
been confirmed by the experience at the University of Michi­
gan.13 After adopting a process of full disclosure of medical
errors, complications, and unexpected outcomes, the Uni­
versity Health System experienced a significant reduction
in malpractice claims and costs. Between 2001 and 2007,
costs per claim dropped by 50 percent, as did the number
of claims.13
The process adopted by the University Health System
involved an internal peer review to identify unreasonable
care, informing the patient of the error, and apologizing. If
the case caused injury, the University, which is self-insured,
would work with the patient to determine appropriate
References
1. Collar County Medical Malpractice New Suits, Law Bulle­
tin Publishing Company, Reflecting Filings through 2013
in Illinois Counties Including Cook County, Illinois
2. 735 Ill. Comp. Stat. 5/2–622
3. James JTA. A new, evidence-based estimate of patient
harms associated with hospital care. J Patient Saf 2013;
9(3):122–128
4. NPDB Research Statistics, National Practitioner Data Bank.

Statistics.jsp
5. Kantzavelos M. Keeping a litigation scorecard. Chicago
Lawyer Magazine, 2011; Cook County Jury Verdict Re­
porter Reports from 2011–2014, Law Bulletin Publishing
Company
6. Reichel SV, et al. Circuit Court Case No. CL03000133—00.
Roanoke City, VA: 2003
7. Shiffman MA. Mastopexy and Breast Reduction: Principles
and Practice. Berlin: Springer-Verlag; Heidelberg; 2009
8. Tovey JH. Medical malpractice—reduction mammoplasty.
67 Am Jur Trials 1998;57:§31
9. Potter v. H. Kern Wisner, M.D., P.C., 170 Ariz. 331, 823 P.2d
1339 (Ct. App. Div. 1 1991); Jacobs v. Painter, 530 A.2d
231 (Me. 1987)
10. Klein v. South Shore Cosmetic Surgeons P.C. et al, Case No.
22 NY. J.V.R.A. 6:C4 (2005)
11. Aills v. Boemi Case FL. No. SC08–2087 (2010)
12. Hugh v. Ofodile, NY Appellate 87 A.D.3d 508 (2011), 929
N.Y.S.2d 122, 2011 NY Slip Op 6329 (2010)
13. Boothman RC, Blackwell AC, Campbell DA Jr, Commiskey
E, Anderson S. A better approach to medical malpractice
claims? The University of Michigan experience. J Health
Life Sci Law 2009;2(2):125–159
14. Gallagher TH, Studdert D, Levinson W. Disclosing harmful
medical errors to patients. N Engl J Med 2007;356(26):
2713–2719

Case Scenarios
Case 1: Tuesday, 7:15 am, preoperative holding area: Dr. A, a
surgeon, approaches the anesthesiologist with an aggres­
sive posture. “What are you doing, cancelling my case?”
The anesthesiologist responds calmly but firmly that the
patient is hyperglycemic and has abnormalities in her uri­
nalysis that should be resolved before the procedure can be
safely done. The surgeon shouts, “You f–ing idiot! I could
do this procedure in my office with my eyes closed!” The
anesthesiologist attempts to close the interaction, walking
past the surgeon, who grabs him by the collar and pushes
him into the wall. This is observed by the patient, nurses,
and residents, and security is called.
Case 2: Thursday, noon, ambulatory surgery center: Dr. B
has blocked time at noon to do a 3-hour case. He arrives at
11:45 and is told the room is not ready. At 12:10 he is told
that they brought up the wrong instruments and his are not
yet sterilized and it will take about an hour to have his full
setup ready to go. The patient, who is the wife of the Chair
of Orthopedics, is NPO and anxious to get the procedure
over with and asks what is happening. Dr. B says, “This OR
is run by idiots and the nurse manager is an incompetent
b—” as he storms out of the room. The nurse, overhearing
this conversation, approaches the patient and apologizes.
“I’m sorry. That’s just how he is, but he is a good surgeon
when he is not shouting at people.” The nurse involved does
not report the incident. Rather, it is reported to the Chair of
Surgery by the Chair of Orthopedics.
These scenarios are familiar and represent an unfortunate
yet common reality for everyone who works in the fren­
zied environment of the operating room (OR). This chapter
addresses the nature of disruptive behavior; its prevalence,
causes, and impact, and strategies for management of indi­
vidual incidents and institutional actions.
Causes of Disruptive Behaviors
The OR is often a tense, rapidly evolving, and anxiety-
provoking environment where seconds count and hierar­
chical gradients are the rule rather than the exception, and
failure of communication can lead to interpersonal conflict
and disruptive behavior.1 Many “tense” communications
occur between team members during each OR procedure,
with some of these resulting in outright conflict.2,3 As illus­
trated in Table 9.1, causes of these unacceptable and poten­
tially dangerous behaviors include factors endogenous to
the disruptive individual and exogenous factors related to
a stressful health care environment.4,5 Disruptive behavior
is not always as it appears. Sometimes disruptive behavior
can be a sign of medical disease (cognitive decline, depres­
Disruptive Behavior: The Imperative
for Awareness and Action
Sheri A. Keitz and David J. Birnbach
CHAPTER
9
Table 9.1 Causes of disruptive
behavior
Individual factors
Exogenous factors
Threatened self-esteem
Unhealthy work culture
Insecurity
Workplace stress
Anxiety
Unrealistic productivity
targets
Personality disorders
Understaffing
Depression
Rigid hierarchical boundaries
58

59
Chapter 9 Disruptive Behavior: The Imperative for Awareness and Action
rupts communication, reduces workplace morale, and may
ultimately result in patient harm.11
Disrespect may be passive, consisting of a range of un­
cooperative behaviors. Leape et al4 beautifully summarized
this, stating “whether because of apathy, burnout, situa­
tional frustration, or other reasons, passively disrespectful
individuals are chronically late to meetings, respond slug­
gishly to calls, fail to dictate charts or operating notes in a
timely fashion, and do not work collaboratively or coopera­
tively with others.”
Prevalence of the Problem
The prevalence of disruptive behavior has been described
across a spectrum of health care settings. One report showed
that 91% of perioperative nurses had experienced at least
one incidence of verbal abuse in the previous year12; another
stated that 67% of nurses reported between one and five in­
stances of disruptive behavior in the previous month.13 Dis­
ruptive behaviors have been directly observed by attending
physicians and medical students in plastic surgery programs,
with more than half of health care providers reporting di­
rect observation of bullying or intimidation, dishonesty,
and confidentiality violations and more than 70% reporting
witnessing poor anger management.14 Anesthesiologists are
often on the receiving end of such behaviors, and 64% of an­
esthesiologists have reported observing disruptive behavior
in the perioperative setting.15 Similarly, 73% of respondents
in one study observed a coworker who was the target of
inappropriate behavior.16 Interestingly, observing a disrup­
tive behavior event can be as damaging to the observer as
it is to the target of the behavior.16 Misbehavior in the OR is
well known to hospital administrators and hospital leader­
ship, who may be complicit in allowing these problems to
continue. More than 95% of physician executives reported
knowledge of disruptive physician behavior within their or­
ganization.17 Potential reasons for organizational reluctance
to deal with disruptive behavior include cultural inertia, fear
of antagonistic physician reactions, organizational hierarchy,
lack of organizational commitment, and ineffective struc­
ture or policies.18
Trainees
Tomorrow’s physicians (including both medical students
and residents) are commonly directly or indirectly involved
in disruptive behaviors. Because of the hierarchy seen in
medicine, they are often mistreated by both attending
physicians and nurses. Medical student mistreatment has
been documented by the Association of American Medical
Colleges (AAMC) for more than 25 years through questions
on the annual Medical School Graduation Questionnaire.
Public humiliation is the most commonly reported form,
with approximately one third of all students reporting ei­
ther public belittling or humiliation. In a meta-analysis of
51 studies including 38,353 trainees, the pooled prevalence
of harassment and discrimination was approximately 60%.
Verbal abuse, gender discrimination, academic harassment,
sion, uncontrolled diabetes), and other times it might sig­
nal alcohol or substance abuse.6
Disruptive Behaviors
There is no single universally accepted definition of disrup­
tive behavior, but the American Medical Association (AMA)
defines it as follows: “Personal conduct, whether verbal or
physical, that negatively affects or that potentially may neg­
atively affect patient care constitutes disruptive behavior.
(This includes but is not limited to conduct that interferes
with one’s ability to work with other members of the health
care team.) However, criticism that is offered in good faith
with the aim of improving patient care should not be con­
strued as disruptive behavior.”7 We prefer the more simple
definition of “any behavior that impairs the medical team’s
ability to achieve intended outcomes.”8 Examples of disrup­
tive behavior are highlighted in Box 9.1.9 Highly inappropri­
ate actions and any action with the potential for imminent
danger, including throwing or breaking things, and use of
a threat of unwarranted physical force must be dealt with
immediately.4
Abuse does not need to be physical to have a major im­
pact on outcome. Verbal abuse is an endemic phenomenon
in the OR and has numerous deleterious sequelae. For ex­
ample, uncivil behaviors have been shown to decrease work
effort, time on the job, productivity, and performance.10
Another important problem that may directly or indi­
rectly relate to disruptive behavior is that of institutional
intimidation. This can manifest as passive-aggressive behav­
iors and gossip, which ultimately result in a negative and
potentially incendiary environment. This phenomenon is
often less overt than disruptive behavior on the part of in­
dividual health care providers but is nonetheless common
and damaging. Because it is difficult to quantify, the victims
often feel helpless and are less likely to report this problem.
Those guilty of such behaviors come from every level of the
health care organization. This “insidious intimidation” dis­
Box 9.1
•• Use of profanity
•• Disrespectful mannerisms
•• Insulting, demeaning, or abusive language
•• Boundary violations
•• Gratuitous negative comments
•• Passing severe judgment
•• Censuring colleagues in front of patients
•• Outbursts of anger
•• Bullying
•• Jokes regarding race, ethnicity, religion, sexual
orientation, age, physical appearance, or
socioeconomic status
Examples of Disruptive
Operating Room Behavior

SECTION II LEGAL AND SAFETY ISSUES
60
dermine morale.4 The Joint Commission33,34 requires that
a code of conduct be established in each hospital defining
“disruptive and inappropriate” behaviors and also requires
that a process for managing disruptive and inappropriate
behaviors be created and implemented.
Identification, Investigation, and Fair
Peer Review
Whenever disruptive or disrespectful behavior is reported,
appropriate action should be taken and leadership should
be involved in ongoing plans. Leape and colleagues9 have
suggested that the organization’s leader is ultimately re­
sponsible for creating a culture of respect, because only he
or she can set the tone and initiate the process that will
lead to change across the organization. Effective policies
for managing disruptive behavior should include fairness,
consistency, graded response, restorative process, and the
presence of surveillance mechanisms. In addition, others
within the institution must be able to share in any lessons
learned from such actions. To change culture, it is neces­
sary to create awareness of the problem so that others are
motivated to take action.35
When a disruptive physician has been identified, the
first step should be a rapid, fair, and thorough review of the
allegation that obtains all perspectives of the situation, in­
cluding that of the alleged disruptive individual, without
taking sides. Input should be sought from relevant supervi­
sors and multidisciplinary team members, including nurs­
ing, administration, and staff, and impartiality should be
maintained. This will allow everyone involved to feel that
their right to respectful treatment is honored.
After the unbiased data collection, a synthesis of find­
ings usually allows the reviewer to assess whether the
findings support or refute the allegations that were made,
or whether there were insufficient findings to allow for
evidence-based conclusions. Also, any immediate threats to
patient or staff safety should be identified and addressed.
Supervisor (typically the department Chair) input should
be sought to identify prior behaviors to determine whether
a sustained pattern has emerged that may modify inter­
pretation of the current incident. The results of the review
should be dealt with in accordance with institutional rules,
policies, and any potential legal standards that may apply.
General Counsel or institutional officials in the Human Re­
sources department or the Office of Faculty Affairs may be
of assistance. Once a decision has been reached, potential
interventions, consequences, and next steps should be dis­
cussed to address the incident being reviewed. A document
outlining the steps of review, findings, relevant policies, and
chosen actions should be created for the faculty file. De­
pending on the hospital or university bylaws, this document
should be shared with the faculty member, when appropri­
ate. A final step should always be to focus on institutional
learning; specifically, institutional opportunities to remove
barriers, improve systems, or educate team members should
be identified and acted upon in a continuous improvement
framework.
sexual harassment, and racial discrimination were com­
mon.19
At one academic medical center, 93% of interns re­
ported experiencing disruptive behavior, with 54% re­
porting the frequency to be once a month or more.20 The
interns cited nurses as a common source of disruptive be­
haviors, including condescending behavior (74.6%), exclu­
sion from decision-making (43.7%), yelling or raising the
voice (24.1%), inappropriate jokes (23.6%), and berating
(20.3%) as commonly experienced behaviors.20 Residents
and medical students seldom report disrespectful acts be­
cause they fear reprisal or vindictive retaliation, such as a
lower grade, critical evaluation, or a poor recommendation
for residency applications.4 In the AAMC Medical Student
Questionnaire, only one third of respondents who were
mistreated reported incidents of mistreatment to their fac­
ulty or administrators, with nearly half citing fear of repri­
sal (48%) as the reason they did not report. Furthermore,
21% of trainees reported a lack of clarity about what to do,
and 37% reported a sense of futility, feeling that reporting
the incident would not be effective.21
Residents can also be the perpetrators of disruptive be­
havior. Sanfey and colleagues22 recommend the following
steps for dealing with disrespectful behavior in residents: re­
flection, increase in self-awareness, punitive consequences,
simulation activities, and structured mentoring.
Consequence of Disruptive Behaviors
Disruptive behaviors wreak havoc on workplace morale
and team function and are related to adverse patient events
and disruption of patient safety efforts.4,23,24
Immediately after an incident, the recipient of such be­
havior may lose the ability to think clearly and decrease fo­
cus and concentration. These are associated with errors in
decision-making or unsafe acts. Long-term effects include
decreased morale, high turnover, reduced team collabora­
tion, failure to comply with system processes, and reduced
information transfer.4,25,26
Disruptive behavior also has financial effects, threaten­
ing hospital image and decreasing nursing satisfaction and
retention of health care personnel.27 This is a major issue in
the current era of difficulty in being able to recruit and re­
tain nurses.18,28 Furthermore, disruptive behaviors have been
shown to have a negative effect on “process flow,” which can
also significantly impact a hospital’s finances.18,29
Solutions
Clearly conflicts and responses to aggressive behavior are
common occurrences in the OR, and conflict management
tools and educational programs should be incorporated
into OR management.2,30 Effective leadership and the im­
plementation of proper preventive measures are neces­
sary to prevent severe dysfunction and disruptive behav­
ior.31,32 Tolerating disruptive behaviors ultimately supports
and reinforces them. Allowing such behaviors to continue
(regardless of financial concerns) has been shown to un­

61
Chapter 9 Disruptive Behavior: The Imperative for Awareness and Action
ior change to restore the clinical environment to one that
is safe and highly functioning and should include a mecha­
nism for surveillance.9 Box 9.3 illustrates graduated inter­
ventions recommended by Hickson.8
Creating a culture in which such reviews can take place
and interventions can be successful involves a multifaceted
approach. The reporting of disruptive incidents is a crucial
part of the process. Traditional obstacles to reporting are the
reluctance to report a fellow coworker, the fear that report­
ing will lead to retaliation, or previous experiences of report­
ing without seeing any action or improvements.38 Therefore
educational programs must also deal with the importance
of timely and accurate reporting.
Proactive Measures
Although most organizations are at the stage of seeking to
create a culture of respect and processes for managing dis­
ruptive behaviors, the best organizations are working to
establish programs and paradigms in which the code of
conduct is understood and actions are taken to proactively
prevent disruptive behaviors. Early identification, perfor­
mance management, education about sexual harassment,
and referrals to professional coaches, anger management,
and faculty-staff assistance programs have all been used to
prevent and manage unprofessional behaviors in academic
medicine.30 Educational programs that are interactive will
maximize discussion and self-reflection.39 Other approaches
that have been reported are the development of an inter­
view tool using situational interview techniques to predict
disruptive physician behavior during the interview process
and the 360-degree feedback process to improve emotional
intelligence.40,41
Many of the previously reported interventions focus on
communication training. For example, one report found that
a 2-day communication skills training program increased
perioperative nurses’ perceived self-efficacy to address dis­
ruptive physician behavior. In addition, participants re­
ported an improved ability to address disruptive physician
behavior.32 Similarly, a hospital in New York implemented a
broad sweeping initiative to create a code of mutual respect
to require respectful behavior as well as steps to implement
Physicians who are accused of abusive or disruptive be­
havior may actually be innocent of such behavior. In fact,
the label of “disruptive physician” has been used by hospi­
tals to control physician behavior and perform “economic
credentialing.” Zbar and colleagues36 reported that “be­
cause of the hemorrhaging of revenue, some hospital ad­
ministrators have taken the easy route of labeling surgeons
who remove better paying cases to private ambulatory sur­
gery centers as disruptive.” The need to protect providers
who respectfully and appropriately identify concerns or
call for institutional improvement is directly referenced in
the second part of the AMA definition of disruptive behav­
ior: “However, criticism that is offered in good faith with
the aim of improving patient care should not be construed
as disruptive behavior.”7
Reviews involving disruptive physicians may have le­
gal implications and dire career consequences and should
be undertaken with meticulous attention to fairness, clear
documentation, and appropriate due process. Organizational
leadership, commonly including a chief medical officer or
leader of the practice group, may engage input from Gen­
eral Counsel’s office if revocation or nonrenewal of clinical
privileges is being considered. Legal guidance will also be
critical—for example, if there is a question as to whether
a physician’s behavior and institutional management has
to be reported to a State Medical Board. Central to any po­
tential legal review, the organization’s policies and proce­
dures should be followed and documented consistent with
the organization’s bylaws. When direct patient care is in­
volved, the peer-review process should be engaged as a ba­
sic component of institutional safety and quality assurance
programs intended to assess and maintain standards of care.
Guiding principles for a hospital’s peer-review process are
outlined in Box 9.2.37
Effective Management of Disruptive
Behavior
When an individual is determined disruptive, a process
should be initiated for feedback, training, and, when neces­
sary, disciplinary action. The response and action should
be graded so that it is proportional to the nature of the in­
cident, as well as mindful of prior behavioral patterns. The
intent of the management process is awareness and behav­
Box 9.3
•• Informal conversations for single incidents
•• Nonpunitive “awareness” interventions when
data reveal patterns
•• Leader-developed action plans if patterns
persist
•• Imposition of disciplinary processes if the plans
fail
Graded Interventions for
Handling Disruptive Behaviors
Box 9.2
•• They must operate with a reasonable belief that
they are improving the quality of patient care.
•• They must only make their decision to revoke
or refuse renewal of staff privileges after a
reasonable effort to obtain the facts.
•• They must provide a fair hearing.
Guiding Principles for a
Hospital Peer-Review Process

SECTION II LEGAL AND SAFETY ISSUES
62
fair, thorough, and swift review of circumstances must oc­
cur, including understanding of the factors that may have
contributed to this outburst, such as physical or mental ill­
ness, work overload, burnout, or personal crisis. However, it
must be clear that there is no acceptable reason for physical
violence in the work setting; in this sense, the institution
must focus on the behavior; the “why” doesn’t matter. Dr.
A cannot return to the work environment until and unless
there is a high level of confidence that there will be no re­
currence. Simple apology, while important, is not sufficient.
Whether return to work is possible will depend on contrib­
uting factors as well as his personal insight and commit­
ment to change. Individuals who have repeated physical
outbursts or egregious behavioral offenses may not be re­
mediable, underscoring the importance of keeping records
on such events and communication with supervisors about
any prior incidents. Because of the potential for severe con­
sequences, up to and including termination, Dr. A’s case
from beginning to end needs to be carefully coordinated
with Human Resources, General Counsel, and health system
leadership. Closing the loop with those who witnessed the
incident is extremely important. They should be told that
this incident was inconsistent with institutional behavioral
expectations and that it is being seriously managed with
diligence. Administrators can provide reassurance that ap­
propriate steps are being taken without violating any con­
fidential information or specifics of potential sanctions.
Finally, because actions speak louder than words, if Dr. A
returns to work with continued misbehavior, it will further
undermine trust in leadership and the safety and integrity
of the work culture.
the code. Implementation involved training to provide skills
for “code advocates” and for mediating conflicts, plans to
identify and address operational systems issues, and an ac­
countability and measurement process.42
High-fidelity simulation is a promising method to en­
hance teamwork and communication among OR personnel
and to thereby reduce potential friction that may occur as a
result of difficulty in communication and in understanding
each other’s roles.43 It has been reported that using high-
fidelity medical simulation is more representative of clini­
cal care and is the “proper paradigm in which to perform
teamwork training.”44 One particular area that can be greatly
improved through simulation-based learning is acquiring
adaptive behaviors and trust among team members.45
Resolution of Case Scenarios
Given the prevalence of disruptive behavior in the operat­
ing room and the magnitude of negative effects, a system­
atic approach is required for management. Box 9.4 offers
ten tips for managing disruptive behaviors.
Case 1: Dr. A’s behaviors escalate quickly from disruptive
to dangerous when he crosses the line and creates a physi­
cal confrontation with the anesthesiologist. In this circum­
stance, there is an immediate need to restore safety. Dr. A
should be removed from the work environment to perform
a thorough review. Physical confrontation represents an ur­
gent red flag, as would other physical expressions of anger
such as throwing an instrument, punching, choking, or hit­
ting. These acts have no place in the clinical setting and can
be construed as assault with potential criminal charges. A
Box 9.4
Everyone is entitled to a swift, thorough, fair, and confi­
dential review of a reported incident.
1. Don’t jump to conclusions. Always start with a fair
and thorough review of facts.
2. Seek supervisory input to assess for context, prior
incidents, and patterns of behavior.
3. Look for red flags that suggest a more difficult
problem, and assess for safety.
Interventions should be consistent and comply with in­
stitutional and legal requirements.
4. Review relevant policies and seek guidance from
General Counsel and Human Resources.
5. Always document and close the loop, including
with the complainant.
6. Be consistent and hold all members of the health
care team to the same behavioral standard.
7. Interventions should balance support and under­
standing with firm accountability.
8. For serious violations and those that directly
threaten safety, focus on the behaviors; the
“why” doesn’t matter.
Management and prevention require an institutional
culture of safety.
9. The best management of disruptive behavior is
prevention through training, leadership, and a
culture of institutional high behavioral standards.
10. Safe reporting is a necessary first step, including
multiple confidential or anonymous mechanisms
for expressing a concern.
Ten Tips for Managing Disruptive Physician Behavior

63
Chapter 9 Disruptive Behavior: The Imperative for Awareness and Action
nurse in this case may not feel that she can safely report
the incident, because the patient is a VIP and she may fear
retribution from the surgeon. This underscores the need
for having multiple mechanisms for safe reporting (e.g.,
through supervisors, anonymous reporting systems, and
compliance hotlines).
Conclusion
The Critical Role of Leadership and
Work Culture
In both of the cases presented in this chapter, the physi­
cians involved cannot ultimately succeed without commit­
ment of top leadership to a uniform, highly respectful work
environment. For example, if the Surgery Chair cannot role
model respectful behaviors and appropriately mentor Drs.
A and B, there is little chance that behavior change will
be sustained. In many organizations, top leaders have not
been trained or provided with the tools to know how to
manage disruptive behavior. Thus the best organizations
manage and prevent disruptive behaviors through skilled
and enlightened leaders, clear policies, and procedures to
ensure consistently implemented interventions and conse­
quences.
Case #2: Dr. B responds poorly to a problem in the man­
agement of the OR and makes inflammatory and dispar­
aging remarks about the nurse manager. It is evident that
this is not the first such outburst in the nurse’s apology to
the patient. Her response also illustrates a common conun­
drum in the OR: Surgeons can be knowledgeable, produc­
tive and technically skilled, and therefore their behaviors
may be tolerated and even normalized (“that’s just how
he is”). Normalization of deviance cannot be tolerated. In
this case, a swift, thorough review may well reveal multiple
contributors to the incident and opportunities for interven­
tion both at the system level and regarding the individual
surgeon’s behavior. As in Case 1, although the administra­
tion must seek to understand and address system factors
(the “why”), inflammatory and disrespectful comments,
profanity, and bullying behavior cannot be tolerated and
must be remediated. Although Dr. B may have felt more
pressured because the patient is the wife of a department
Chair and colleague, his disruptive behaviors will further
decrease the patient’s perception of the OR environment,
the institution, and the staff and are unacceptable. This
physician might be referred to anger management, com­
munications training, or an employee assistance resource to
help him develop skills to manage stressful situations more
effectively. Mentoring and close follow-up by his supervisor
will be critical to meaningful behavior modification. This
case also highlights the difficulty in “safe” reporting. The
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