Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Breasts (Figure 14.4)
FIGURE 14.4 Standard positioning and views of the breasts. Clavicles positioned at the top of the frame; torso centered
horizontally for frontal/oblique views.
(Used with permission of the American Society of Plastic Surgeons.)
Patient should have all jewelry and gown completely removed and be given a photo garment to
wear.
Patient should stand comfortably with arms to the side and positioned at a premarked area in the
examination room. Distal arms should be moved back slightly for oblique views.
Clavicles should be positioned at the top of the frame. The torso should be centered horizontally for
frontal and oblique views. The proximal breast should be centered horizontally for lateral views; the
distal breast should no longer be visible.
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Abdomen (Figure 14.5)
FIGURE 14.5 Standard positioning and views of the abdomen. Inframammary folds positioned at the top of the frame; torso
centered horizontally.
(Used with permission of the American Society of Plastic Surgeons.)
Patient should have the gown completely removed and be given a photo garment to wear.
Patient should stand comfortably with arms folded above the breasts and positioned at a premarked
area in the examination room.
The inframammary folds should be positioned at the top of the frame. The torso should be centered
horizontally.
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Hips/Thighs (Figure 14.6)
FIGURE 14.6 Standard positioning and views of the hips and thighs. Knees positioned at bottom of frame; hips centered
horizontally.
(Used with permission of the American Society of Plastic Surgeons.)
Patient should have their gown completely removed and given a photo garment to wear.
Patient should stand comfortably with arms folded above the breasts and positioned at a premarked
area in the examination room.
Knees should be positioned at the bottom of the frame, with the hips centered horizontally. The
distal leg should not be visible in the lateral view.
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Hand and Forearm (Figure 14.7)
FIGURE 14.7 A. Fingers straight in palmar view. B. Clenched fist in palmar view. C. Fingers straight in lateral view. D.
Clenched fist in lateral view. E. Fingers straight in dorsal view. F. Clenched fist in dorsal view.
Patient should have all jewelry and nail polish removed.
Patient should be seated on a stool and directly face the camera operator. Both hands should be held
a few inches above a table/background; the patient should avoid touching the background to prevent
distortion of the natural finger posture.
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Patient’s hands should be lined up at the fingertips.
A set of six standard views of both hands should be photographed.
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Lower Extremity (Figure 14.8)
FIGURE 14.8 Standard positioning and views of the lower extremity. Toes positioned at bottom of frame; feet centered
horizontally.
(Used with permission of the American Society of Plastic Surgeons.)
Patient should have all clothes and jewelry below the waist completely removed; nail polish should
also be removed.
Patient should stand on a step stage with feet at shoulder width.
Toes should be positioned at the bottom of the frame, with feet centered horizontally. The distal leg
should not be visible in the lateral view.
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Application of Videography in Plastic Surgery
In recent times, videography has quickly become an important adjunct not only in the documentation of
patient outcomes for scientific presentations and research, but in facilitating effective surgical education
and physician-to-physician communication as well. High-quality videos are able to capture all stages of
the surgery (if needed), while still ensuring enough detail to adequately demonstrate the pertinent
surgical anatomy. Thus, videography adds context for scientific presentations to be more understandable
in comparison to the use of figures or schematics. 15-20 Furthermore, owing to the increasing use of social
media outlets by plastic surgeons (e.g., YouTube, Facebook, Instagram, Twitter, SnapChat), high-quality
videos can successfully augment plastic surgeons’ online repertoire when presenting their techniques and
outcomes to prospective patients.
Well-shot videos promote effective comparison and evaluation of surgical outcomes not only across
different operative techniques, but also among their peers as well. 15-20 Additionally, it is important to
understand that unlike photographs, which capture patients’ preoperative and postoperative conditions,
videos have the advantage of capturing dynamic aspects of an operation. Thus, compared with
photography, videography is much more difficult to standardize, because no two operations in plastic
surgery are performed the exact same way; it is challenging to compare key components of one operation
with key components of another operation (even if they are the same operation). Despite these challenges,
certain aspects of videography in plastic surgery can be standardized, such as camera type, positioning,
and video editing. Maintaining consistency in videography can prove extremely useful, particularly
when comparing preoperative and postoperative functional outcomes. 15,16
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General Concepts of Videography
Equipment
Many types of cameras exist for video recording, from remote-controlled cameras mounted on tripods
and handheld camcorders with swivel screens to operating room light handle cameras, and even newer
generation wearable or head-mounted devices. 15,17-19 Despite the many available options, the majority of
video cameras will be precalibrated to capture the highest-quality images; technical aspects, such as
aperture size and light exposure, will generally be automatic depending on which mode is selected. Thus,
it is less important which device is used when recording videos, and more important that whichever
device one uses, it should be the same device every time to maintain consistency.
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Background
Backgrounds should be kept consistent, particularly when recording a series of videos of the same patient
at different time intervals (e.g., hand function at different periods of follow-up). We recommend either a
sky blue or green background when recording surgical videos, as they are optimal for a wide variety of
skin tones and minimize shadows. 15 Additionally, the surgical field should be cleared of unused
equipment (e.g., retractors, gauze, scissors), as well as any bloodstains or debris, as to not distract viewers
from the important details of the operation.
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Lighting
Whether in the clinic or in the operating room, it is important to use a uniform light source when
recording videos, as nonuniform light can create unnecessary shadows and diminish the image quality.
Thus, ambient operating room fluorescent lights, surgical LED lights, or even flood lights (if in a clinic
studio) should be used to maximize uniformity. 15,16 With improved technology, automatic white balance
capabilities will better compensate for varying light intensities and prevent over-exposure of images.
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Guidelines for Videography
When recording preoperative and postoperative videos, the goal is to capture functional changes in the
specific areas of interest (e.g., facial movements, extremity range of motion). Therefore, to effectively
compare preoperative and postoperative videos, several things should be considered. The patient’s body
area of interest should be positioned the same way each time. The angles at which a video is recorded and
the positioning of certain body areas of interest should be consistent across all recording sessions. Clear
instructions should be given to patients before video recording regarding how they should position
themselves or what motions need to be captured.
For instance, for patients undergoing hand procedures, the hand should be positioned with its
longitudinal axis going from left to right across the screen, as opposed to up and down. The patient
should be asked to slowly move the joint or area of interest at least three times and in three different
views (i.e., dorsal, medial, and palmar). 15 Similarly, if a patient is undergoing cleft surgery, the patient’s
face should be positioned within the field of view consistently each time. The same video angles should
be used during each session, and the patient should be asked to repeat the same phrases and make the
same series of lip movements during each view. 16 Only by carefully coordinating these details will it
allow the surgeon to effectively compare and evaluate surgical outcomes and ensure quality.
When recording intraoperative videos, the goal is to capture and illustrate the dynamic aspects of an
operation. Thus, the video operator should know and understand the procedure being performed, as well
as all the pertinent steps and relevant anatomy. Having a full understanding of these key aspects of an
operation guarantees that no unnecessary video memory is wasted and, more importantly, that no time is
wasted by the operating surgeon trying to communicate the critical steps of the operation at hand. 15
If using a handheld camcorder, it is essential that the camera operator always position himself or herself
directly behind the operating surgeon to capture video from the surgeon’s point of view. Alternating
perspectives from the operating surgeon to the assistant is disruptive to the viewers in understanding the
pertinent anatomy in the operation. The videographer should take the pictures and videos from the
operating surgeons’ vantage point. It is also critical to maintain good ergonomics when recording video
in order to minimize user fatigue and motion. For instance, the videographer’s elbows should be tucked
in to the body instead of in an outstretched position to avoid excessive arm movement while recording
and fatigue. A poorly recorded video footage can be detrimental to the final product and often cannot be
salvaged later during the editing process. 15 Additionally, the videographer should avoid zooming in and
out with the camera, which can make the video appear haphazard. 15 Of note, these considerations may
not be as relevant when using mounted devices, such as GoPro cameras. However, there are apps that are
available for certain mounted cameras that allow an assistant to remotely control the recording process.
18,19
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Conclusion
Photography and videography are important aspects of plastic surgery, aiding in surgical education,
medicolegal documentation, and most importantly, assessment of patient outcomes to gauge quality. In
this age of quality metrics and rating systems, it is important for surgeons to document carefully and
learn from past mistakes. The guidelines set forth in this chapter provide direction in the best way to
standardize photography and to record videos. As always, before capturing any photographs or videos, it
is important to obtain patient informed consent to use the recorded material in order to comply with
Health Insurance Portability and Accountability Act (HIPAA) regulations. Patient identifiers, such as
name, address, or medical record numbers, should be excluded from all forms of media.
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Questions
1. Which of the following are enhanced as a result of standardizing photography and videography in
plastic surgery?
a. Effectively tracking, evaluating, and comparing surgical outcomes
b. Gauging quality and learning from mistakes
c. Aid in medicolegal documentation
d. All of the above
2. A 44-year-old woman presents to your clinic in consultation for a TRAM flap. When taking her
preoperative and postoperative photographs, a lens of what focal length would be most appropriate?
a. 50 to 60 mm
b. 60 to 70 mm
c. 80 to 90 mm
d. 90 to 105 mm
3. What color background has been proven to be the most effective and visually pleasing?
a. Black
b. White
c. Sky blue
d. Green
4. Which of the following are examples of uniform light sources?
a. Ambient operating room fluorescent lights
b. Surgical LED lights
c. Studio flood lights
d. All of the above
5
You are using a handheld camcorder in the operating room to record the attending surgeon perform
a trapeziectomy with ligament reconstruction. Where is the best place to stand when shooting this
video?
a. Directly behind the first assistant at all times
b. Directly behind the operating surgeon at all times
c. Alternating between standing behind the operating surgeon and the first assistant depending
on the operative step
d. Wherever will give you the best image
1. Answer: d. Maintaining a high level of consistency when capturing photographs or recording
videos will enhance all of the abovementioned. Thus, it is essential to establish standardized
guidelines for photography and videography in plastic surgery.
2. Answer: a. Lenses with a short focal length range of 50 to 60 mm are ideal for body contouring and
photographs that use a large area (e.g., breast and abdomen). Lenses with a longer focal length range
of 90 to 105 mm are ideal for closer photographs (e.g., face and head).
3. Answer: c. Sky blue background has been studied extensively and deemed by the Clinical
Photography Committee to be the most visually pleasing background color, independent of whether
the photograph is taken in black and white or in color; it provides sufficient color contrast to various
skin tones and diminishes the appearance of shadows. Black background tends to provide less
contrast for darker-skinned patients, whereas white background tends to produce harsh shadows.
4. Answer: d. Ambient operating room fluorescent lights, surgical LED lights, and flood lights (if in a
clinic studio) are all examples of uniform light sources. Using uniform light sources minimizes
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unnecessary shadows and maximizes image quality.
5. Answer: b. It is essential that the camera operator always position himself or herself directly
behind the operating surgeon to capture video from the surgeon’s point of view. Alternating
perspectives from the operating surgeon to the assistant confuses the viewers and impairs proper
understanding of the pertinent anatomy.
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References
Henderson, JL, Larrabee, WF Krieger, BD. Photographic standards for facial plastic surgery. Arch Facial Plast Surg. 2005;7(5):331-333.
Wang, K, Kowalski, EJ, Chung, KC. The art and science of photography in hand surgery. J Hand Surg Am. 2014;39(3):580-588.
Hamilton, GS, Carrithers, JS, Karnell, LH. Public perception of the terms “cosmetic,” “plastic,” and “reconstructive” surgery. Arch Facial Plast
Surg. 2004;6(5):315-320.
Szychta, P, Zielinski, T, Rykala, J, Kruk-Jeromin, J. The internet as a source of information for patients prior to rhinoplasty. Clin Exp
Otorhinolaryngol. 2011;4(3):131-136.
Sanniec, KJ, Velazco, CS, Macias, LH, et al. Adherence to Photographic Standards: a review of ASPS and ASAPS member surgeons’ websites.
J Aesthet Reconstr Surg. 2016;2:11.This article evaluated how closely ASPS and ASAPS members adhered to the published photographic standards set
forth by the Plastic Surgery Educational Foundation (PSEF) in 2006. The authors evaluated members’ websites and reported that only approximately
66% of members adhered to PSF standards.
Hagan, KF. Clinical photography for the plastic surgery practice: the basics. Plast Surg Nurs. 2008;28:188-192.
DiBernardo, BE, Adams, RL, Krause, J, et al. Photographic standards in plastic surgery. Plast Reconstr Surg. 1998;102(2):559-568.Among the
first definitive guidelines published on photographing patients using specific anatomic landmarks and standardized views for the general plastic and
reconstructive practice.
Ettorre, G, Weber, M, Schaaf, H, et al. Standards for digital photography in cranio-maxillo-facial surgery. Part I: basic views and guidelines. J
Craniomaxillofac Surg. 2006;34(2):65-73.This article proposes a European-wide set of standards for the range of photographic views for
craniomaxillofacial surgery, including both intraoral and facial photographs. It also provides important assistance on selecting the proper software and
equipment necessary to ensure high-quality photographic documentation.
Gherardini, G, Matarasso, A, Serure, AS, et al. Standardization of photography for body contour surgery and suction-assisted lipectomy.
Plast Recontr Surg. 1997;100(1):227-237.
Neff, LL, Humphrey, CD, Kriet, JD. Setting up a medical portrait studio. Facial Plast Surg Clin North Am. 2010;18(2):231-236.
Yavuzer, R, Smirnes, S, Jackson, IT. Guidelines for standard photography in plastic surgery. Ann Plast Surg. 2001;46(3):293-300.
Zarem, HA. Standards in photography. Plast Reconstr Surg. 1984;74(1):137-146.
Archibald, DJ, Carlson, ML, Friedman, O. Pitfalls of nonstandardized photography. Facial Plast Surg Clin North Am. 2010;18(2):253-266.
Plastic Surgery Educational Foundation. Photographic Standards in Plastic Surgery. American Society of Plastic Surgeons; 2006.This guide was
developed by the Plastic Surgery Educational Foundation (PSEF) to maintain consistency when taking preoperative and postoperative photographs in
the clinic/studio setting. The guide standardizes camera settings, background, lighting, framing, and patient positioning and poses across various body
areas of interest.
Rehim, AR, Chung, KC. Education video recording and editing for the hand surgeon. J Hand Surg Am. 2015;40(5):1048-1054.This article
outlines the key considerations involved in choosing the necessary software and hardware, as well as the technical aspects of recording, editing, and
archiving videos in hand surgery.
Morrant, DG, Shaw, WC. Use of standardized video recordings to assess cleft surgery outcomes. Cleft Palate Craniofac J. 1996;33(2):124-142.
Sandri, A, Hunt, D, Rhobaye, S, Juma, A. Video recording of surgery to improve training in plastic surgery. J Plast Reconstr Aesthet Surg.
2013;66(4):e122-
Vara, AD, Wu, J, Shin, AY, et al. Video recording with a GoPro in hand and upper extremity surgery. J Hand Surg Am. 2016;41(10):e383-e387.
Graves, SN, Shenaq, DS, Langerman, AJ, Song, DH. Video capture of plastic surgery procedures using the GoPro HERO 3+. Plast Reconstr
Surg Glob Open. 2015;3(2):e312.
Kucuker, I, Keles, MK, Aydoğdu, IO. An easy and applicable method for capturing high-quality rhinoplasty videos: handle banded
camcorder. Plast Reconstr Surg. 2013;132(6):1082e-1084e.
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C H A P T E R 1 5
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Principles of Psychology for Aesthetic and
Reconstructive Surgery
Sergey Y. Turin and Sammy Sinno
Key Points
Psychological nuances must be considered when caring for both aesthetic and reconstructive
patients.
Surgeons tend to underestimate the prevalence of psychiatric disorders in their patients, yet these
comorbid conditions can place the patient at a high risk for postoperative dissatisfaction.
Strong data show positive effects on psychologic well-being and quality of life for breast
reconstruction, congenital and acquired deformity correction, as well as for addressing aesthetic
concerns.
Surgeons should always consider the psychologic facets of the patients’ complaints and the treatment
options offered, both to improve the patient-doctor relationship and to enhance satisfaction rates, as
well as to identify the patients with psychiatric comorbidities who may be poor surgical candidates.
Both aesthetic and reconstructive procedures aim to restore congruency between the patient’s own body
image and the corporeal self. Accomplishing this hinges equally on the surgeon’s operative results as well
as on patients successfully adapting their body image to this result. The importance of the psychological
aspect should not be underestimated, as psychologic complications may be more frequent than surgical
or medical complications and can have a detrimental impact on the overall outcome, including time to
return to work, quality of life, and satisfaction with the surgical result. 1
Concepts particular to aesthetic or reconstructive surgery will be discussed separately only for the sake of
clarity in organization, because the psychological framework underpinning patient attitudes and
motivations is very much the same. Although the etiology of the presenting complaints may be different,
the magnitude of its impact on the patient and the amount of expected improvement are similar: aesthetic
patients report similar levels of dissatisfaction with their overall appearance and concern for the feature
in question as reconstructive patients. 2
A comprehensive understanding of the psychologic aspects of the patient’s complaint is key to ensuring a
shared mindset when discussing surgery and will build a stronger patient-surgeon relationship as well as
improve the likelihood of patient satisfaction with the end result. This process is rooted in identifying
three variables: (1) the presenting complaint (e.g., dorsal hump, unfavorable scar, or mastectomy defect);
(2) the patient’s attitude toward this feature (i.e., his or her level of concern and impact on quality of life,
as well as source of concern—pressure from significant other, professional expectations, or self-
motivated); and (3) amount of motivation for surgery. These variables can then be evaluated in the
context of the surgeon’s objective assessment of the defect and his or her skill set to determine the
likelihood of delivering a satisfying result.
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Principles of Psychology in Plastic Surgery
Psychology in plastic surgery often focuses on the congruence of the patient’s body image and the
objective appearance, as the idea of body image is pivotal to the concept of the patient’s relationship with
his or her body. Body image, simplistically, may be thought of as the individual’s subjective experience of
his or her body, and it includes all facets of that experience: functional (e.g., dysphagia, loss of limb
function, or ability to perform a task), sensory (e.g., pain, paresthesia, anesthesia), and outward
appearance (e.g., deformity, scarring). It is important to always recognize that body image is subjective,
and therefore must be understood in a social context. 3,4 These concepts can explain the seeming
disconnect between an objectively minor deformity and the great level of distress it causes to the patient,
or the drive toward the currently en vogue appearance or look. If a patient’s body image and appearance
are aligned, then changes in his or her appearance due to injury, age, or disease may cause distress if the
body image does not change accordingly. Similarly, a patient can suffer the same distress if his or her
body image and physical appearance are never aligned, as in the scenario of a congenital malformation or
body feature that is never incorporated into the body image.
Another key concept applicable specifically to any intervention is patient expectations. It is incumbent on
the surgeon to verify what the patient expects as a result of the surgery, and that the surgeon is able and
willing to deliver that result. Again, the body image the patient is seeking may be subjective, so an
excellent result in the surgeon’s eyes may be a failure for the patient if he or she was not pursuing the
same goal. With this in mind, the term defect, as used in this text, will be used to denote the deficiency
perceived by the patient, whether it may be a disfiguring feature or a lack of the desired aesthetic feature,
as they are, in principle, psychologically the same.
It has been said that satisfaction is result divided by expectation, and when the expectations are well
defined, this relationship holds. 5 Clarity and openness in communication is key, and this dovetails with
the concepts of informed consent—a well-defined goal and an honest discussion of the risks are not only
the basic foundation of informed consent, but also set up a healthy relationship in case of complications.
The last general principle is that a surgeon can deliver a surgical result but cannot always deliver the
emotional effects the patient desires—his or her well-being, self-perception, and satisfaction will all be
derived from the relationship between the result and the patient’s goals. The more direct and strong that
relationship, the more likely the patient is to be satisfied. To illustrate the concept, consider a patient with
a single painful neuroma who only desires relief from the pain, and delivering this result will almost
certainly guarantee satisfaction. This is in contradistinction to a patient desiring any surgery the surgeon
considers appropriate to improve the looks in the hope of attaining a promotion at work. The surgeon does
not have a clearly defined result to deliver, and the patient is seeking a vague improvement for a
secondary gain, setting both parties up for disappointment.
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The Psychology of Aesthetic Surgery
Multiple studies provide evidence that aesthetic procedures have high satisfaction rates and improve
patients’ quality of life and sexual well-being, and help them look younger, more attractive, healthy, and
successful. 6-8 However, these positive outcomes can depend as much on the patient as upon the surgical
result. As an extreme example, a patient with body dysmorphic disorder (BDD) is unlikely to be satisfied
regardless of how excellent the surgical result may be. 9-11
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Patient Perspective
Goals and Expectations
The patient’s goals and expectations must be clearly delineated as they may not be one and the same. For
example, a patient presenting for breast augmentation may be expecting an increase in her breast size
with no complications and an acceptable scar, yet the goal may be to salvage a troubled relationship. In
this scenario, meeting the expectations for the surgical result has no guarantee of the patient achieving
her goals. Unless this is clarified and understood, she may still risk dissatisfaction with her surgery
despite a good surgical result.
Clarity and shared understanding should be the guiding principles when discussing the defect and the
intended surgical result. Although surgeons and patients usually agree in their general assessment of the
body part in question, perception of the details and their relative importance may be different. 12
Surgeons’ assessment tends to be comprehensive in the sense of understanding the defect, the available
interventions, their risks, and likely outcomes. On the other hand, the patient will almost always be
limited in his or her understanding of surgical concepts relevant to the etiology of the defect and its
treatment, such as focusing on the protuberant mandible without appreciating a concave midface. It has
been shown that patients are reliably able to understand the basics of a procedure, but an in-depth
understanding is usually lacking. 13 It falls to the surgeon to bring both parties to consensus on all of these
points.
Instruments have been proposed to introduce a systematic method to assessing patient suitability for
surgery (both subjective and objective), 14 yet none have gained wide acceptance at this time. An
empathetic, individualized approach still remains the cornerstone of patient counseling, and there is yet
no substitute for time spent in consultation.
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Confounding Factors
Probably more so than any other area of health care, aesthetic surgery is governed by the laws of demand
and supply, with sensitivity to price and behavior akin to a luxury good. 15 Although many aesthetic
practices are forced to compete on the basis of cost, the surgeon is well advised to prioritize excellent
patient care instead of discounts to expand the practice. 16 Moreover, pricing can be a confounding factor
in patient decision-making, and extra care must be taken that the patient is well informed and has
appropriate and organic motivations for surgery as opposed to being financially motivated to take
advantage of a special offer.
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Psychiatric or Personality Disorders
Multiple studies have shown a relatively high prevalence of psychiatric diagnoses in the plastic surgery
population, reaching as high as 48% to 70%, 17,18 with up to 50% of patients receiving psychotropic
medication. This has prompted the question of whether standardized psychological screening tests
should be incorporated into the routine plastic surgery patient evaluation, 19 but no consensus exists on
the topic at this time. Disorders such as BDD or bipolar personality disorder (BPD) have an extreme
impact on patients’ postoperative recovery and mental acceptance of the result. In these patients, the
psychiatric process may have a greater bearing on the patient’s satisfaction than the actual surgical
outcome and may put the surgeon at risk for an unhappy, adversarial patient regardless of the result. We
will discuss BDD and BPD as these are the more common diagnoses the surgeon will encounter that also
carry the highest risk.
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Body Dysmorphic Disorder
Epidemiology
The prevalence of BDD in adults in the general population is estimated at 1.9% but is reported to be as
high as 6% to 33% in patients presenting for cosmetic surgery, with some of the higher numbers seen in
rhinoplasty patients. 11,20-22 Plastic surgeons are aware of this disorder but tend to underestimate its
prevalence in their own practice 23 : in one multicenter study, 9.7% of all patients screened positive for
BDD using a validated screening tool, but only 4.0% raised the surgeon’s suspicion. 24
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Presentation
Per the DSM-5, BDD is defined as an obsessive-compulsive or related disorder, with the diagnostic
criteria detailed in Table 15.1. 25
TABLE 15.1
Diagnostic Principles for Body Dysmorphic Disorder 25
There are four main elements to making a diagnosis of body dysmorphic disorder:
The patient is preoccupied with one or multiple more subjective flaws in his or her appearance that would be objectively considered
minimal or within the range of normal by others.
This preoccupation hinders patient functioning in some way (social, professional, etc.).
This preoccupation is or has been associated with repetitive behaviors, such as frequent mirror checking, manipulation of the body
feature in question, etc.
There is no other better-suited diagnosis that would explain the patient’s symptoms. For example, concerns regarding body habitus
in a patient who is suffering from an eating disorder would be best attributed to the eating disorder rather than BDD.
Patients may exhibit excellent to poor insight into their condition and the correlation of their beliefs with the objective truth. While
pertinent to future psychotherapy, neither situation changes the mainstays of diagnosis as described above.
The most common complaints are perceived defects of the skin, hair, eyes, nose, and teeth, explaining
why these patients seek treatment by dermatologists, cosmetic dentists, orthodontists, and plastic
surgeons. 26
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Impact
BDD patients experience dissonance between their body image and their appearance primarily because
their body image is distorted, even as their appearance may not change. The nature of this disorder
makes it impossible to deliver a surgical result that will satisfy the patient, exactly because the patient’s
complaint is a psychiatric one disguised as a physical feature. Failure to recognize BDD and treat the
patient correctly incurs not only a very high risk of an unhappy patient, but also legal liability even if the
objective result is satisfactory, as the BDD patient dissatisfied with surgery falls into the category of victim
11 because of his or her underlying psychiatric condition.
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Management
There is no consensus on the optimal method of screening for BDD in the plastic surgery practice.
Routine screening with existing psychiatric surveys 27 may be the ideal approach, but the limitations of a
busy practice have led to poor adoption of routine screening outside of cases raising suspicion for BDD.
Surgery for the presenting complaint is ill-advised, if not contraindicated, 9-11 as multiple series have
shown that cosmetic surgery in patients with BDD provides no benefits and may even cause an
exacerbation of the condition, resulting in a patient who is beyond unhappy, sometimes resorting to
litigation, 10 attacks on the surgeon’s reputation and practice, or even violence. 28 However, there may be
patients who can be successfully treated with a multidisciplinary approach combining psychiatric and
surgical care, 29 thus suggesting that BDD may not always be a hard contraindication to surgery.
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Summary
The prevalence of BDD in an aesthetic practice is likely higher than clinically suspected, and these
patients require very different care. Although presenting with a physical complaint, the true pathology is
psychiatric and must be treated as such. Surgical intervention is associated with a prohibitively high rate
of dissatisfaction, so identifying these patients early is crucial to ensure they receive appropriate care.
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Bipolar Personality Disorder
Epidemiology
BPD is a common mental disorder characterized by impulsive behavior and instability of emotions,
interpersonal relationships, and self-image, with a prevalence of up to 9% in plastic surgery population.
18,30
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Diagnosis
One of the notable features of BPD as opposed to BDD is the concern with multiple features. It has been
suggested that such patients may be more precisely diagnosed with BPD and comorbid BDD, as opposed
to the opposite. Splitting is also a core feature of BPD. Signs and features of BPD that should raise
suspicion in a plastic surgery patient include 30 :
Female gender (dominant)
Age early 20 to 30s
History of other psychiatric disorders (especially depressions and other personality disorders)
History of adverse events during childhood
History of multiple aesthetic procedures with doctor shopping
Self-harm behavior (e.g., cutting, burning) or suicidal ideation
Tattoos and multiple body-piercings
Psychosocial impairment (but some individuals show good psychosocial adjustment)
Dissatisfaction or anger toward the previous surgeon
Splitting phenomenon toward the surgeon or clinic staff
Concern with one or more body parts, which is less profound and shifts from one to another over
time
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Management
Operating on a patient with BPD predictably runs a high risk of extremely poor patient satisfaction, 11,18
with some patients directing anger or disappointment at family, friends, clinic staff, or the surgeon, going
so far as litigation or even violence such as self-mutilation. 30,31 The surgeon is advised to be empathetic
and understanding in the counseling process, enabling the patient to be aware that surgery without an
appropriate indication will not only fail to solve the problem, but may exacerbate it.
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Summary
BPD patients tend to focus on multiple issues, request multiple revisions due to fear of abandonment, are
quick to split, and have disproportionally worse postoperative satisfaction. As in BDD, the principal
complaint is most likely actually psychiatric, rather than physical, and recognizing this prior to any
surgery will help the surgeon avoid the poor postoperative outcomes so prevalent in these patients.
Many screening tools are available for personality disorders, but there is not one that has shown itself to
be the optimal solution. 32 At this time, surgeons are still best advised to use their own judgment and refer
to the many available questionnaires when suspicion for psychopathology is raised. The surgeon should
be exceedingly weary of any surgical intervention in these patients as the risks of dissatisfaction and
adverse outcomes are very high.
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External Influences
When considering the patient’s motivation for surgery, it is important to recognize the presence and
magnitude of extrinsic influences. The stereotypical example is a patient presenting for a procedure to
satisfy his or her significant other’s preferences, as opposed to desiring alteration of a body feature to
conform to the patient’s own body image. The pervasive role of mass and social media in our everyday
lives has expanded the influence of social trends and beauty standards, and patient attitudes reflect this.
33 The majority of patients will thus request their actual appearance align both with their self-image and
with the prevailing social concepts of beauty and attractiveness.
Intuitively, meeting the expectations of the patient is easier to accomplish than additionally meeting those
of the significant other or some other social group. It is, of course, imperative to avoid any intervention in
a patient that may be coerced into seeking it against his or her will, but the surgeon must otherwise be the
judge in determining what is or is not an appropriate mix of intrinsic or extrinsic motivation. Some
warning signs of external influences inappropriately affecting patient judgment include:
A controlling or overbearing spouse or significant other that drives the consultation—in this
scenario, if able, interview the patient alone (or with a chaperone if there is any suspicion of abuse or
harmful manipulation) to clarify his or her own attitudes and goals to more appropriately evaluate
the suitability for surgery
A secondary goal as the main driving factor, such as expecting the surgery to salvage or change a
personal relationship, results in workplace advancement or some other aspirations that are
ultimately not under the patient’s control. The risk here lies in the possibility of failing to achieve this
secondary goal despite a good surgical outcome, ultimately leading to patient dissatisfaction. The
stereotypical example is a patient requesting a facelift or breast augmentation with the goal of
salvaging a relationship—the real goal is not a rejuvenated face and neck or enhanced breast contour
and size, but changing the behavior of another person—something that no surgeon can promise
A desire to comply with a social trend against their own preferences, again an example of attempting
to fulfill the desires or expectations of someone other than the patients themselves
The surgeon must always exercise his or her judgment in evaluating each patient individually—as social
beings, the majority of the decisions we make are guided by the desire to please others as much as
ourselves, but the patients too strongly influenced by external factors must be evaluated thoroughly to
minimize the chance of disappointment on their part.
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Physician Perspective
Adverse Outcomes
Complications, however rare, can happen even in the best of hands and can weigh heavily on the
surgeon. The emotional toll of an adverse outcome can be high in aesthetic cases, which by definition is
elective and makes a well person temporarily unwell in the hope of an eventual improvement. 34
The nonoperative management of poor outcomes hinges on the principles described earlier, customized
to each patient and founded on empathetic care. Frequent postoperative visits, time spent face-to-face,
and honest efforts to rectify the situation can salvage patient expectations and even result in overall
positive reviews despite experiencing a surgical complication. The patient with a personality disorder or
unrealistic expectations that were not clear preoperatively is treated in the same fashion, focusing on
treating the underlying psychiatric issue. These cases may be distressing and disruptive to the practice,
yet no clear algorithm or protocol exists for addressing such concerns, except that involving a mental
health professional sooner rather than later and thorough documentation. Empathetic care
postoperatively can sometimes allow the patient to still walk away with an overall positive appreciation
of his or her care. 35
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Litigious and Adversarial Patients
The burden of litigation, when encountered, weighs heavily on the physician and its costs are not
insignificant, even though the majority of cases are still won by the physician. 36 Documentation of good
surgical practices and informed consent are of prime importance in dealing with a litigious patient, as
these activities are integral to the defense. Moreover, after claims for poor outcomes due to lack of
expertise, lack of informed consent is a frequent cause for legal action, again underscoring its importance.
37 Because the decay of the patient-physician relationship cannot always be foreseen ahead of time, it is
important to practice these good habits proactively.
Given the evidence for surgeons underestimating the prevalence of psychiatric disease in their patients,
there should be a low threshold to involve mental health professionals. Unfortunately, that may often
come too late, as patients with factitious disorders are liable to continually switch surgeons when
psychiatric evaluation is suggested, only undergoing the formal psychiatric evaluation when forced to do
so for a trial.
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The Psychology of Reconstructive Surgery
Patient Perspective
Goals and Expectations
The breadth of reconstructive surgery presents many unique psychological scenarios. Patients who
acquire a deformity tend to seek a return to their baseline state to restore harmony with their established
body image. Patients with congenital deformities would align psychologically with many aesthetic
patients, in that their body image and appearance were not congruent at baseline. In either scenario, the
goal for these patients is restoration of their normal/baseline selves to fit in their social environment, and
surgery may be the best option as psychotherapy is often ineffective. 38 As in aesthetics, the patient’s
psychological state has a great impact on recovery and attitude toward the results of the surgery, as
shown by the strong correlation between preoperative life satisfaction and coping ability and
postoperative recovery course. 39
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Oncologic Reconstruction
As in aesthetic surgery, it is key to understand that the psychologic burden may not correlate to the
degree or type of deformity: some scar revision patients report levels of dissatisfaction with their body
appearance and preoccupation that could be consistent with BDD. 2,4,40
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Breast Reconstruction
Mastectomy is known to inflict a psychological burden upon the patient, altering the patient’s perception
of her feminity, cascading into mood and interpersonal relationship sequelae. 41 Fortunately, breast
reconstruction can ameliorate and reverse some of the negative impact of mastectomy. Specifically,
immediate breast reconstruction appears to impose a lower overall psychological burden on the patient
than delayed reconstruction, potentially sparing the patient from some of the psychological burden of
mastectomy. 42 Contrary to some previous notions, it appears the patients do not appreciate the
reconstruction more or feel like there is relatively more improvement after having to live with their
deformity in cases of delayed reconstruction. 43 Multiple studies have shown a benefit to quality of life
and subjective well-being after breast reconstruction, such that the issue in question is now access to
reconstruction, as opposed to any argument over its value in restoring not only the physical body feature
but the patient’s self-image and social function. Moreover, even when postoperative complications are
encountered, reconstruction is still beneficial as patients tend to recover predictably from the
psychological burden of the complications experienced.
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Amputation and Neuroma Pain
Aside from the well-known functional impact of amputation, many patients develop chronic pain due to
neuromas at the amputation stump, leading to significant secondary morbidity due to this constant
painful stimulus. Chronic pain affects the patient on many levels and can result in fatigues, sleep
disturbance, alteration of social function, and mood disorders due to the constant stressor effect it creates
in the patient. Intervention can be efficacious in treating these secondary effects, as successful surgical
treatment of neuroma pain has been shown to have a positive impact on self-reported depression and
quality of life. 44
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Congenital Anomalies and Orthognathic Surgery
The wide variety of congenital anomalies corresponds to an equally wide variety of patient attitudes
toward them. When discussing surgical intervention, the patient who is more satisfied with the
appearance preoperatively is likely also be satisfied with the appearance postoperatively, demonstrating
the ability to adapt the self-image to the appearance in a healthy fashion. In general, evidence shows
improved adaptation to social functioning after reconstruction or correction of congenital deformities, as
illustrated by patients with microtia reporting improvement in body image and life satisfaction after ear
reconstruction, 45 similar to cleft lip/palate patients after undergoing delayed repair. 46 Many patients
adapt their self-image and show good coping with the deformity. For example, patients with cleft
lip/palate report a high prevalence of teasing focused on the cleft stigmata, but the majority grow up to be
well-adjusted and well-functioning adults 47 despite some persistence of social and psychologic stigmata
of the cleft. 48 Other craniofacial deformities demonstrate the same pattern. 49
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Physician Perspective
As reconstructive techniques continue to advance, surgeons are able to salvage and reconstruct
increasingly more complex defects. Taking care of patients with challenging problems often results in a
close relationship between the surgeon and patient, as both become invested in each step of the process
and the eventual outcome. Surgeons know firsthand the importance of clear thinking and mental
fortitude in the face of complications and difficulties in the operating suite. The patient’s state of mind
and attitudes can be just as important, but inadequate psychologic preparation may only become
apparent postoperatively when the patient is unable to comply with the rigorous demands of
rehabilitation. Anticipating stressful scenarios and situations that may cause psychologic strain on the
patient and addressing these issues ahead of time will pay dividends in these scenarios. In both aesthetic
and reconstructive scenarios, patient expectations and self-image are a key factor in their satisfaction and
success of the surgical process. The surgeon should have a low threshold to offer psychological help and
counseling to patients undergoing prolonged or complex reconstruction to maximize the chances of the
patients being in the optimal state of mind before and after the surgery.
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Conclusion
Psychology is a key component of plastic and reconstructive surgery because it can determine the
patient’s acceptance and satisfaction with the operative result independently of the objective outcome.
Failure to account for this variable may result in an unhappy patient despite a well-planned and executed
surgical plan. This concept applies both to healthy patients presenting for aesthetic surgery and patients
with congenital or acquired defects presenting for reconstructive surgery, as the driving motivation is the
same in both groups: correction of some defect (whether subjective or objective) to restore congruity
between the patient’s body image and the corporeal self.
The plastic surgeon should be aware of warning signs for patients with personality disorders, unrealistic
expectations, or poor coping skills that would place them at risk for a poor psychological outcome. These
psychological factors present in the minority of patients but can have disproportionately large effects and
thus are important to bear in mind during patient evaluations.
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Questions
1. A 24-year-old woman comes to the office requesting rhinoplasty. She is bothered by the
appearance and asymmetry in her nose. She spends several hours each day looking in the mirror at
her huge hump and wide tip. On examination, she has excellent symmetry, a 1 mm hump, well-defined
dorsal aesthetic lines, and tip defining points. What is the most appropriate next step?
a. Scheduling the patient for septoplasty
b. Scheduling the patient for rhinoplasty
c. Psychiatric referral
d. Injectable fillers to camouflage the dorsal hump
2. A 45-year-old man is presenting to your office requesting correction for gynecomastia. He has had
a negative medical workup for it and reports that the appearance of his chest has bothered him since
childhood. When discussing his social history, he reveals that he and his spouse have been going
through a rough patch and a few months ago decided to separate for a year. He eats a healthy diet and
exercises four times a week but has stayed the same weight for more than a decade. On examination,
he is a slightly overweight male with bilateral breast enlargement that is mostly adipose with little
glandular tissue. What is the appropriate next step?
a. Schedule the patient for gynecomastia correction with liposuction.
b. Ask the patient to return at the end of the separation period with the spouse.
c. Refer the patient to a psychiatrist for more thorough evaluation.
d. Ask the patient to lose more weight prior to surgery.
3. A 21-year-old woman presents to the office for breast augmentation. She is accompanied by her
boyfriend, who states that he will be paying for the procedure, and they are interested in a
promotion for saline implants that your practice has advertised recently. She reports that her breast
size has been stable “around a B cup” for 3 or 4 years and that she “wouldn’t mind if they were
bigger, maybe even as much as a DD cup that he [the boyfriend] wants.” On examination, she has
fairly symmetric breasts with no ptosis, masses, or other anomalies. What is the next step?
a. Counsel the patient on saline versus silicone implants and then discuss sizing.
b. Ask the patient to obtain a psychiatric evaluation prior to further discussion.
c. Tell the patient that she must be the one to pay for surgery.
d. Ask to examine her with a chaperone, without the boyfriend present, to clarify her own
motivation and expectations for surgery.
4. A 35-year-old woman presents to your office for a scar revision consultation. She suffered a deep
laceration to the left thigh in a motor vehicle collision during her childhood and has been unhappy
with the scar ever since. She finds herself unable to go out in public for fear of people ostracizing her
because of the scar and worries about it constantly. She has tried all available scar creams and
therapies and has had four revisions in the past. She reports that her previous surgeons had treated
her poorly and discriminated against her because of her multiple tattoos and piercings, which is why
they took out the sutures too early, causing scar widening. On examination, the left lateral thigh has
a 10 cm linear scar, which is widened to about 5 mm and is slightly raised. There are also multiple
narrow linear scars on her thighs and forearms that are tattooed over. What is the next step?
a. Tell the patient that after four revisions, the likelihood of improvement is minimal and that
you would advise against surgery.
b. Confront the patient about her doctor shopping.
c. Suggest to the patient that surgical intervention is unlikely to make her feel better about her
appearance, and suggest counseling with a possible surgical reevaluation afterward.
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d. Schedule the patient for scar revision.
5. A 35-year-old right hand–dominant male steelworker presents with pain in the left forearm after a
traumatic amputation 2 years ago at work. He reports pain at the distal end of the stump with
pressure and touch. He has not been fitted for a prosthetic of any kind and has not been participating
in any rehabilitation as he has compensated with his right hand. His spouse, who accompanies him,
reports that he lost motivation after the accident and has been in a poor mood, withdrawing from
social activities and spending all his time at home. On examination, he has a mid-forearm
amputation with two points distally that elicit severe pain with percussion, but it otherwise appears
well healed. The spouse asks you what they can expect if surgery to treat the neuromas is successful?
a. He will be able to be fitted for a prosthesis and improve his function.
b. His pain will improve, reducing the amount of pain medications necessary, but counseling
and rehabilitation will likely be needed to restore his functional capacity.
c. He will be able to take advantage of rehabilitation services to retrain for a new position at
work.
d. Even though the pain will be addressed, the psychologic morbidity of the amputation will
likely persist as a permanent disability.
1. Answer: c. Although this may not provide enough data to make a definitive diagnosis of BDD, two
warning signs are listed: preoccupation with what is described as a minor deformity and repetitive
behavior (mirror checking). Surgical intervention is not indicated until a more thorough psychiatric
evaluation of the patient is carried out either by the surgeon or by a mental health provider.
2. Answer: a. This patient reports a long-standing concern with his chest, with a negative hormonal
workup and a stable weight. He does not exhibit any signs of disproportionate concern with the
deformity. He does not indicate that he is trying to change his appearance for a secondary gain.
Given that he is otherwise a good surgical candidate, surgery would be an appropriate next step.
3. Answer: d. Although many patients will be seeking their significant others’ advice or support
when considering surgery, it is important to recognize when these external influences become
overbearing or inappropriate. In this scenario, the boyfriend appears to be the primary motivator for
the patient seeking surgery. The surgeon should investigate the patient’s own attitudes and desires
to ensure that she will be happy with the result as well.
4. Answer: c. Multiple clues should raise the suspicion of bipolar disorder in this patient—splitting
behavior, doctor shopping, signs of self-harm, etc. Leaving aside the idea of whether a fifth scar
revision can be indicated, the patient’s psychologic status makes her a poor candidate for a surgical
intervention. Although mostly anecdotal, existing literature supports avoiding a direct confrontation,
which will usually lead to an angry patient who will then move on to the next practice. Although it
may get the patient out of the office in the short term, it does not help address the real issue at hand.
A sensitive approach and steering the patient toward mental health care instead of an outright
refusal to treat is the more compassionate and diplomatic way of dealing with this patient.
5. Answer: b. Treatment of neuromas can address the painful sensory symptoms, both from the
neuromas being directly stimulated and due to phantom pains. There can be secondary positive
change after relief of these pains such as improvement in function with or without prosthesis fitting,
improvement in quality of life due to reduction in pain medications, and maybe return to work.
However, these do not directly result from a successful surgery—accomplishment of these goals will
depend on the patient and so cannot be guaranteed (although relief of chronic pain does improve the
chances of the patient improving in other areas). Similar to an aesthetic surgery not guaranteeing a
promotion at work, the relief of pain does not guarantee an improvement in other areas of life.
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References
Borah, G, Rankin, M, Wey, P, Borah, G. Psychological complications in 281 plastic surgery practices. Plast Reconstr Surg. 1999;104(5):1241.
Sarwer, DB, Whitaker, LA, Pertschuk, MJ, et al. Body image concerns of reconstructive surgery patients: an underrecognized problem. Ann
Plast Surg. 1998;40(4):403.This is one of the high-quality articles dealing with self-image in the reconstructive population, showing the parallels to the
aesthetic patient.
Pruzinsky, T. Who chooses to undergo reconstructive surgery? Empirically confirming the subjectivity and social basis of body image. J Burn
Care Rehabil. 1997;18(4):372.
Heinberg, LJ, Fauerbach, JA, Spence, RJ, Hackerman, F. Psychologic factors involved in the decision to undergo reconstructive surgery after
burn injury. J Burn Care Rehabil. 1997;18(4):374.This is an important study showing that psychosocial factors were far better correlated with burn
victims undergoing reconstructive surgery, as compared with the severity of their deformity
Morselli, P, Micai, A, Boriani, F. Eumorphic plastic surgery: expectation versus satisfaction in body dysmorphic disorder. Aesthet Plast Surg.
2016;40(4):592.
Stofman, GM, Neavin, TS, Ramineni, PM, Alford, A. Better sex from the knife? an intimate look at the effects of cosmetic surgery on sexual
practices. Aesthet Surg J. 2006;26(1):12.
Shridharani, SM, Magarakis, M, Manson, PN, Rodriguez, ED. Psychology of plastic and reconstructive surgery: a systematic clinical review.
Plast Reconstr Surg. 2010;126(6):2243.
Bater, KL, Ishii, LE, Papel, ID, et al. Association between facial rejuvenation and observer ratings of youth, attractiveness, success, and health.
JAMA Facial Plast Surg. 2017;19(5):360-367.
Crerand, CE, Franklin, ME, Sarwer, DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e.
Sarwer, DB, Crerand, CE, Didie, ER. Body dysmorphic disorder in cosmetic surgery patients. Facial Plast Surg. 2003;19(1):7.
Honigman, RJ, Phillips, KA, Castle, DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg.
2004;113(4):1229.
Shipchandler, TZ, Sultan, B, Ishii, L, et al. Aesthetic analysis in rhinoplasty: surgeon vs. patient perspectives : a prospective, blinded study.
Am J Otolaryngol Head Neck Surg. 2013;34(2):93.
Hoppe, IC, Ahuja, NK, Ingargiola, MJ, Granick, MS. A survey of patient comprehension of readily accessible online educational material
regarding plastic surgery procedures. Aesthet Surg J. 2013;33(3):436.
Rees, L, Myers, S, Bradbury, E. A comprehensive screening, education, and training tool for the psychological assessment of patients seeking
aesthetic surgery: “desirable op?” Aesthet Plast Surg. 2012;36(2):443.
Alsarraf, R, Alsarraf, NW, Larrabee, WF, Johnson, CM. Cosmetic surgery procedures as luxury goods: measuring price and demand in facial
plastic surgery. Arch Facial Plast Surg. 2002;4(2):105.
Rohrich, RJ. The market of plastic surgery: cosmetic surgery for sale: at what price? Plast Reconstr Surg. 2001;107(7):1845.
Ishigooka, J, Iwao, M, Suzuki, M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998;52(3):283.
Napoleon, A. The presentation of personalities in plastic surgery. Ann Plast Surg. 1993;31(3):193.
Meningaud, JP, Benadiba, L, Servant, JM, et al. Depression, anxiety and quality of life among scheduled cosmetic surgery patients:
multicentre prospective study. J Craniomaxillofac Surg. 2001;29(3):177.
Picavet, VA, Prokopakis, E, Gabriels, L, et al. High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plast
Reconstr Surg. 2011;128(2):509.
Veale, D, Gledhill, LJ, Christodoulou, P, Hodsoll, J. Body dysmorphic disorder in different settings: a systematic review and estimated
weighted prevalence. Body Image. 2016;18:168.
Sarwer, DB, Wadden, TA, Pertschuk, MJ, Whitaker, LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery
patients. Plast Reconstr Surg. 1998;101(6):1644.
Sarwer, DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a Survey of American Society for
Aesthetic Plastic Surgery Members. Aesthet Surg J. 2002;22(6):531.
Joseph, AW, Ishii, L, Joseph, SS, et al. Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and
oculoplastic surgery clinics. JAMA Facial Plast Surg. 2017;19(4):269-274.
American Psychiatric Association. Obsessive-compulsive and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
American Psychiatric Association; 2012.
Phillips, K. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press; 1996.This is
a landmark publication from Dr. Phillips on BDD, comprehensively describing its diagnosis and treatment.
Claiborn, C, Perdick, C. The BDD Workbook. New Harbinger Publications; 2002.While perhaps not easily available, this is a good example of a BDD
screening tool.
Sweis, I, Spitz, J, Barry, D, Cohen, M. A review of body dysmorphic disorder in aesthetic surgery patients and the legal implications. Aesthet
Plast Surg. 2017;41(4):949.Dr. Sweis et al. provide a very concise and updated review of the evidence available regarding BDD in the aesthetic surgery
population.
Edgerton, MT, Langman, MW, Pruzinsky, T. Plastic surgery and psychotherapy in the treatment of 100 psychologically disturbed patients.
Plast Reconstr Surg. 1991;88(4):594.
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Morioka, D, Ohkubo, F. Borderline personality disorder and aesthetic plastic surgery. Aesthet Plast Surg. 2014;38(6):1169.This is an outstanding
reference comprehensively covering all aspects of BPD in the aesthetic patient population.
Davis, RE, Davis, RE, Bublik, M. Psychological considerations in the revision rhinoplasty patient. Facial Plast Surg. 2012;28(4):374.
Wildgoose, P, Scott, A, Pusic, AL, et al. Psychological screening measures for cosmetic plastic surgery patients: a systematic review. Aesthet
Surg J. 2013;33(1):152.
Crockett, RJ, Pruzinsky, T, Persing, JA. The influence of plastic surgery “reality TV” on cosmetic surgery patient expectations and decision
making. Plast Reconstr Surg. 2007;120(1):316.
Gorney, M. Recognition and management of the patient unsuitable for aesthetic surgery. Plast Reconstr Surg. 2010;126(6):2268.
Dorfman, RG, Purnell, C, Qiu, C, et al. Happy and unhappy patients: a quantitative analysis of online plastic surgeon reviews for breast
augmentation. Plast Reconstr Surg. 2018;141(5):663e-673e
Svider, PF, Blake, DM, Husain, Q, et al. In the eyes of the law: malpractice litigation in oculoplastic surgery. Ophthal Plast Reconstr Surg.
2014;30(2):119.
Kandinov, A, Mutchnick, S, Nangia, V, et al. Analysis of factors associated with rhytidectomy malpractice litigation cases. JAMA Facial Plast
Surg. 2017;19(4):255.
Bessell, A, Moss, TP. Evaluating the effectiveness of psychosocial interventions for individuals with visible differences: a systematic review
of the empirical literature. Body Image. 2007;4(3):227-238.
Kopp, M, Bonatti, H, Haller, C, et al. Life satisfaction and active coping style are important predictors of recovery from surgery. J Psychosom
Res. 2003;55(4):371.
Fingeret, MC, Nipomnick, S, Guindani, M, et al. Body image screening for cancer patients undergoing reconstructive surgery. Psychol Oncol.
2014;23(8):898.
Mendelson, BC. The psychological basis for breast reconstruction following mastectomy. Med J Aust. 1980;1(11):517.
Zhong, T, Hu, J, Bagher, S, et al. A comparison of psychological response, body image, sexuality, and quality of life between immediate and
delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg. 2016;138(4):772-780.
Wellisch, DK, Schain, WS, Noone, RB, Little, JW. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast
Reconstr Surg. 1985;76(5):713.
Domeshek, LF, Krauss, EM, Snyder-Warwick, AK, et al. Surgical treatment of neuromas improves patient-reported pain, depression, and
quality of life. Plast Reconstr Surg. 2017;139(2):407.
Awan, B, Samargandi, O, Aldaqal, S, Sehlo, M. Life satisfaction and quality of life in adolescents with grade III microtia: the effect of
improved body image disturbance after ear reconstructive surgery. Eur Psychiatry. 2014;29:1.
Kapp-Simon, KA. Psychological issues in cleft lip and palate. Clin Plast Surg. 2004;31(2):347.
Crocker, EC, Clifford, E, Pope, BA. The Cleft Palate Child Grows Up an Analysis of the Adulthood of Former Patients. Portland, Oregon: American
Cleft Palate Association; 1970.
Tobiasen, JM, Hiebert, JM. Clefting and psychosocial adjustment: influence of facial aesthetics. Clin Plast Surg. 1993;20(4):623-631.
Endriga, MC, Kapp-Simon, KA. Psychological issues in craniofacial care: state of the art. Cleft Palate Craniofac J. 1999;36(1):3.
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C H A P T E R 1 6
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Patient Safety in Plastic Surgery
Omar E. Beidas and Jeffrey A. Gusenoff
Key Points
Patient selection is important in reducing perioperative risk and postoperative complications
DVT prophylaxis should be considered based on Caprini score
Careful attention should be paid to patient positioning on all cases
Patients should be kept warm before, during, and after surgery
Early ambulation, adequate hydration, and reduced narcotic use can ease postoperative recovery
Patient education of warning signs can aid in avoiding severe complications
Patient safety is perhaps the most important aspect of surgery and begins from the moment the patient-
physician relationship is established. It is the duty of every member of the health care team but ultimately
the responsibility of the surgeon. Attention to detail must be maintained throughout the preoperative,
perioperative, and postoperative periods. This chapter provides the most recent guidelines at the time of
writing. The reader is encouraged to use the online resources referenced herein to adhere to the most up-
to-date recommendations.
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Preoperative Care
Patient Selection and Evaluation
Patient Expectations
With any surgical procedure, it is of utmost importance to manage patient desires and expectations. A
patient’s expectations of the outcome should be aligned with results that the surgeon can reasonably
deliver. If a patient has unrealistic or idealistic expectations, or the surgeon does not believe he or she can
deliver the result expected, then it is best to avoid operating on such a patient.
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Medical Comorbidities
It is critical for a surgeon to tease out certain details of a patient’s history to determine their overall health
and risk for general anesthesia. A quick set of questions to screen for any red flags during the initial
history and physical examination follows. If a patient answers yes to any of the following questions, it
should prompt further questioning and possible testing or referral to the patient’s primary care physician
(PCP) or specialist.
Have you ever had a heart attack or stroke?
Do you get short of breath climbing one flight of stairs?
In nonambulatory patients: if surgery is high risk, consider pharmacologic stress test
Do you use any nicotine products? Do you vape, dip, or use cessation products?
Do you or anyone in your family have a history of abnormal bleeding or clotting?
The complexity of the planned surgical procedure must be considered, as a blepharoplasty will have a
different risk profile compared with that of a free fibula osteocutaneous flap for mandible reconstruction
after resection of a floor of mouth tumor. For surgery involving more than minimal risk, a preanesthesia
unit—if one is available—should assess the patient’s suitability for general anesthesia and order any
necessary tests prior to surgery. Electrocardiograms and/or chest X-rays may be required by anesthesia
personnel; however, this is institution specific. Alternatively, a PCP or other medical specialist familiar
with the patient may provide clearance for the suggested procedure. Management of any medical
comorbidity such as hypertension and diabetes should be left to these physicians. Communication is key
to assure patient safety.
A useful online resource is the American College of Surgeons National Surgical Quality Improvement
Program’s risk calculator (). The calculator considers patient factors—
such as age, functional status, American Society of Anesthesia class, medical comorbidities—and the
procedure to determine a percent risk of common complications. The surgeon may even increase the
estimated risk based on patient factors that are not accounted for by the calculator.
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