ELECTIVE AESTHETIC SURGERY. THE PATIENTS' EXPECTATIONS FOR THE SURGICAL OUTCOME.
There may be many reasons for a patient to consider elective aesthetic surgery. For whatever the reasons, they are often linked to the patients' expectations for the surgical outcome. Most maintain a reasonable outlook for their care, but for those with unrealistic expectations how can we work to maintain an affable relationship with them? You are listening to ReachMD, The Channel for Medical Professionals. Welcome to The Clinicians' Roundtable. I am your host, Dr. Michael Epstein, board certified plastic surgeon. Our guest is Dr. Peter Adamson, Professor of Otolaryngology/Head and Neck Surgery and Head of Facial Plastic and Reconstructive Surgery at the University of Toronto. Sr. Adamson is recognized as an international leader in facial plastic surgery.
DR. MICHAEL EPSTEIN:
Welcome Dr. Adamson.
DR. PETER ADAMSON:
Thank you very much. Nice to be with you!
DR. MICHAEL EPSTEIN:
So, this is an interesting topic. It's certainly something that comes up frequently in my own practice. In terms of percentages, how may problem patients would you say plague a typical practice?
DR. PETER ADAMSON:
Well, like so many things in life, it's a small percentage, but regardless of what type of practice you have, they are the ones which you remember, and I have created something called a patient desirability curve and the abbreviated comment on that would be that the majority of patients we see, thinking any type of practice, really are fairly good patients. Some are better than others, but most we can manage their physical or psychological issues in order to achieve a good outcome. On the other hand, there may be let's say about 5% of patients who within moments of discussing their problems with them, you recognize there may be some significant psychological issues that may not make them a good candidate and there may be another 5% or 10% that I think their physical issues are such that we aren’t going to be able to meet their expectations or make them happy and that leaves us with maybe let's say 10% or 15% at the outside that are what I call marginal patients. These are the ones who are just not quite sure about whether it's from a psychological or physical perspective and they are the ones I feel you really need to spend more time with during your consultation, maybe even have a second consultation, so you can try to best determine whether they are going to fall into the group you don't wish to operate on or you feel that, although marginal, you probably can get them a good results, and if you do make a mistake, this is usually the group that you are going to make a mistake with by operating on someone that later on you say, I wish I had not.
DR. MICHAEL EPSTEIN:
Are you finding that this is probably more of a problem that's specific to elective cosmetic surgery versus the patient that would be deemed more reconstructive that has more of a functional need for surgery?
DR. PETER ADAMSON:
Well, I suspect it may be a little bit higher for the elective patient because after all they come in generally healthy, generally well, and so they can only what should I say get a really good result to be better, whereas the reconstructive patient, the post trauma patient, they have already had a certain loss and they may be much more accepting of a result that's a little bit less than ideal, recognizing, at least I have come along way back towards normal. So, I do believe that aesthetic patients perhaps have higher standards and greater expectations.
DR. MICHAEL EPSTEIN:
Do you think that this is a growing problem or do you think the problem is fairly static throughout the lifespan of plastic surgery?
DR. PETER ADAMSON:
Yeah, well, that's an excellent question, and of course, we all only live in our own time zone professionally as it were, but in reviewing, you know, the older literature, which I tend to do because I do a fair bit of writing and presenting and also just seeing some of the psychological literature around today, it does seem to be that patients today do have higher expectations, so studies of narcissism, for example, indicate that this seems to rising a little bit in the college students in particular through the 1990s and people today, of course, in so many rounds of life expect that thing should be perfect, and if they aren't, then perhaps someone is to blame other than himself, and of course, if you are a surgeon performing elective surgery, then it is pretty easy to find who must be the person who has caused that problem, since it's not you. So, I do believe it's an increasing problem. It's not an epidemic by any means, but I do think we have a very highly expectant and, you know, very critical type of population. We've lived in a society where exceptionalism, I think, has become almost the norm and so many patients do have, I think, an enhanced sense of entitlement about life in general and this does fall over into the aesthetic surgery field.
DR. MICHAEL EPSTEIN:
Why don’t you take us through several typical problem patients, you know, I hate to put you on the spot, but let's see, you know, people come up with a couple ones that, you know, a fairly busy plastic surgeon or facial plastic surgeon would see in their office.
DR. PETER ADAMSON:
Right, well I think one of the types of the patients we not infrequently see and these are, in fact, the end of the day are less bothersome than some of the others I might describe would be the patient having a life crisis. There are quite a few people today, of course, who will go through a divorce or lose a job or life is really stressful right now, and some of them feel that having elective cosmetic surgery may help them to, you know, get that better job or a get a new relationship, as they had a failed relationship and they may, in fact, be really good candidates, but even good things in life like getting married, buying a house, what have you, are still stressful, and so for these kinds of patients, I might say, "listen, I think you're gonna be a good candidate, but life is too stressful for you right now, why don't you put this off for 6 or 12 months and then can review things and you will be able to focus all your energies on the issue at hand, that is, getting better from your surgery." I think a type of patient that we see quite frequently is the "just the unhappy patient," then studies seem to show that roughly speaking about 80% in people in general in the public are fairly happy with their lives. There is about 20% of people who are generally unhappy and I guess if we all think around amongst our friends and colleagues, we can probably identify people who fall into those 2 groups and the point is that people who are generally unhappy, their glass is always half empty rather than half full, they tend to exaggerate the negatives in their lives and it is much harder to take that kind of persons and make them happy with the result of the elective surgery because they are generally not happy about most things in life, and so we try to avoid those unhappy people and recognizing that, and I am sure, you know all of listeners know that the study showed about 9% or 10% of all, you know, Americans will have a depressive episode at a given time and about that many people, you know, may see a psychiatrist or psychologist in any given year or, so this is a pretty common problem that we see and I think we just have to be alert to that in particular.
DR. MICHAEL EPSTEIN:
Would you be able to or have you ever seen any type of objective patient scale or way of ranking the patients for measuring these types of problems that may prohibit them from having surgery?
DR. PETER ADAMSON:
Well, the Minnesota Multiphasic Personality Inventory or the MMPI has been around for a long, long time and certainly even earlier in my career, we actually used an abbreviated form of this to try to identify some of these patients, so I believe this and there are several other different, you know, tools out there. I think though that for the surgeon performing elective cosmetic surgery and, in fact, this would pertain to many other elective surgeries on thinking, for example of infertility treatments or many other things that are really quite elective. I believe the most important thing at the end of the day rather than looking at these kinds or forms as to, you know, read a lot around the psychology related to the types of elective procedures you are performing, and then with experience, I think it very much becomes one of those issues of your gut instinct and, you know, the blink phenomenon. I am sure many, again, of our listeners have read the book Blink, which really just states that you get a feel, I mean look at that patient in a subjective sense, just blink and say, do I feel comfortable with this person or not? I think when you are more inexperienced and younger, sometimes when you are having trouble establishing rapport with the patient, you think, well gosh what's my problem here today? How come I am not able to understand better what they are taking about, why is this not going well? And I think the more experienced you get, you start to realize that, you know it's not me, it's them! So, I have a couple of phrases, which I think are particularly applicable to the patient who might have a personality disorder and sometimes these patients are very hard to thrash out because they don't all come in, you know, with flagrant clinical symptoms. They are often very subtle and some of these patients if they want something done, they will try to hide their history from you or hide some other symptoms and also, of course, as we know many psychological conditions diseases, they wax and wane, so you see the patient once or twice beforehand when they are healthy, and gosh that doesn’t seem so bad, but then they, you know, they wane later on and then you have a patient for life. You only have them once or twice before operation, but you have them for life after, so I use these 2 expressions, there is something missing, there is just something missing with their personality or another expression I ask myself, "they just don't get it", and those are real red flags for me to take a step back and say, what am I dealing with here?
DR. MICHAEL EPSTEIN:
Are you noticing that the numbers of problems may vary with the type of procedure, like you know, I remember back in training that, you know, were always to be aware of the male rhinoplasty patient. In your practice do you see that there is a specific type of procedure that these problem patients are coming for?
DR. PETER ADAMSON:
Yes, and I think you really hit the nail on the head with the male rhinoplasty patient now. I reality, most men are excellent candidates for rhinoplasty. They tend to come more not just for anesthetic concern, but of course, men tend to have had more sports injuries or some of them spent a little bit too much time in bars when they were younger, and we say when they become a lover instead of a fighter, that's the time they consider them for rhinoplasty, but it's well recognized that some men who are having sexual identity crises may dissociate, you know, sexual concerns to their nose and so their nose becomes a big issue, and obviously that person's sexual identity conflicts are not gonna to be resolved by performing a rhinoplasty or feminizing a male nose. So, that's one high-risk individual. Another one that we see and is not common, but in fact, I had a gentleman like this just a few weeks back, and when you see them and you are looking forth, they just hit you on the head with a hammer, and this is the so called Simon syndrome, which stands for the single male obsessive narcissistic individual and these individuals come in and they are just like that, and so these males can be very difficult to please because of their narcissism. Now, that is the male rhinoplasty patient. The female rhinoplasty patient can sometimes be a patient who has had sexual dysfunction as well. If you have a mature woman and you put a nasal speculum in their nose and they recoil with that. This is presumably like you are doing it gently, of course, and appropriately, but if they recoil from that then that's something that you might take as a sign that perhaps, just perhaps, you should delve a little bit further into any issues of sexual dysfunction because once again in women this can be, you know, dissociative from the female genitalia to the nose. I think more in the facial rejuvenation patient, I think there were more concern about the patient who is a chronic depressive or we get patients who may again be a little bit narcissistic and we will worry about those patients and whether we are ever going to able to make them happy. A type of patient that covers both men and women and is a definite potential problem in both facial contour surgery that would be rhinoplasty, otoplasty, malarplasty, and less of an incidence in rejuvenation is the body dysmorphic syndrome, which of course is much written about. Now, the study seemed to show only 1% to 2% of the general population has obsessive body dysmorphic disorder, but it may be, may be, as high as 10% to 15% in the cosmetic surgery patient. This makes sense because if someone has body dysmorphic disorder and they want to get it corrected, where they are gonna go or where they gonna have cosmetic surgery.
DR. MICHAEL EPSTEIN:
I would like to thank our guest, Dr. Peter Adamson.
I am Dr. Michael Epstein. You have been listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. Be sure to visit our website at www.reachmd.com featuring on demand pod cast of our entire library. For comments and questions, please call us toll free at (888 MD XM 157) and thank you for listening.
