Does appearance play a role in negative or positive attitude?

It’s often said that plastic surgery is a form of psychotherapy or psychosurgery. Our objective: improve a patient’s outlook on life, sense of well-being, and advance the playing field of social encounters.

Case in point: It’s difficult to carry on a conversation with someone when you think that all they see is the giant nose on your face or the ugly wart on your chin. Although most of us are raised not to judge on appearance, the reality is that our society values beauty and extends itself to those who take care of their appearance which is a big part of our presentation. Most believe that it is easier to face the world (colleagues, friends, and social acquaintances) without the stigma of what is commonly referred to as ugliness.

Studies show that people are more comfortable around attractive and well-groomed counterparts than those who are unattractive or unkept. Research also proves that attractive people receive more accommodations, promotions, and perks throughout life. This positive/negative response by society can build or diminish self-esteem and self-image.

Difficult Patient or Poor Self-Image?

Poor self-image is a common problem encountered by plastic surgeons. Many times, who we consider an unsatisfactory patient is likely someone exhibiting anxieties associated with poor self-image. Certainly, plastic surgeons can argue that having bigger breasts or a smaller nose does not ensure happiness. But, the majority of patients I consult with do believe that a better body or younger-looking face will lessen the disadvantages they feel over being unattractive—whether in fact they are or think they are.

Realistic Expectations

Some expect perfection in not only themselves, but in others—something humans can  not possibly achieve. When one of these perfection-seeking people becomes a patient, we have to ask ourselves, “Do they need surgery or counseling?” and “Will they accept the limitations of our specialty, or will they brand our efforts inadequate?”

Perfection-seeking people are the reason that I refuse to use an imaging machine. Imaging a patient to perfection does not reflect a surgeon’s ability to get the job done in the operating room. Some physicians consider imaging machines a teaching aide; but patients, especially those seeking perfection, will not be happy if what they saw on-screen isn’t what they get after surgery.

One tool Iuse for perfection-seeking/ potentially difficult people with unrealistic expectation is my “counseling book.” This portfolio contains before-and-after photos  of patients with good, average, and excellent results and allows preoperative patients to see several face and body types and the results that were accomplished. Patients see that perfection is not achievable, but improvement is vast. I believe this is the key to happier post-op patients. Another is to take a photograph of the patient prior to the surgery and again on the third postoperative visit.

Asking Questions Is Not Just for Patients

I’m always wary of patients who ask too many or not enough. It’s vital that physicians supply patients with specific procedure material at the initial consultation and ask them to read it by the second visit when  it’s time to discuss patient expectations. In breast surgery cases, it’s always good to ask a patient her thoughts on size and shape. I ask patients to bring photos from magazines of women who, in their view, have too much, not enough or look just right.

By this time, I have narrowed implant size down to 5 of the 20 or so available, then counsel as to whether she qualifies for the IRB textured and smooth gel study—in my opinion the best way to go for almost everyone. Still, patients come back and say, “I wish I had chosen a larger size.” This patient is not necessarily dissatisfied, but needs to be reminded of what she initially hoped to achieve. I bring out the photos she agreed on and say, “This is what you asked for, and this is what we achieved.” Seeing actual photos helps patients accept the reality of surgical expectations.

A Supportive Office Environment

Most important for patient satisfaction is a supportive office staff. For 25 years, I have offered patients the benefits of a spa located within my office which provides facial-rejuvenation treatments, massages, makeup, and hair washing. It’s a comfortable environment where patients are free to vent their true feelings. The healing aspects of touch and ability to listen cannot be overstated. Patients appreciate a supportive staff who greets them by name, takes time to answer questions, and comforts their fears. These are important to a patient’s recovery and satisfaction level. They mean even more to a potentially dissatisfied patient. Patients deserve star treatment. The more they receive, the more satisfied they are.

Your Best Referrals

Two most common complaints I hear from patients about other physicians are:

• The patient only saw the physician once before and once after surgery. Other times staff filled in. Patients resent this. They do not want staff to care for them when their physician should be available. Patient satisfaction depends on physician availability.

• Scars. “If the doctor can do a breast lift internally with a textured gel implant, why did I end up with giant anchor scars?” This complaint is attached to abdominoplasty, blepharoplasty, and face-lift surgeries. Do not believe that patients are happy with visible scars. They are not. It’s easier to hide incisions during surgery than to listen to complaints. Other surgeons come up with innovative ways to hide scars and it’s our obligation to learn and adapt them into our practices. In my new textbook, The Atlas of Liposuction, we show good, bad, and middling results, along with suggestions from colleagues on how to improve procedure.

With body surgery, don’t overlook fat regrafting. A potentially dissatisfied patient can become a very satisfied patient when he/she sees preoperative photos and finds they got a freebie (fat regrafting) into dimples and flat areas. This applies also to face-lifts. Fill out depressed or atrophic areas around the mouth and frown lines. Ask patients if they would like their lips restored. It takes a few minutes; and when properly performed, it’s a permanent enhancement that makes patients happy.

Patient Red Flags

There are normal people with anxieties and people who are truly psychotic. Our job is not only to operate but to advise patients about their best interests—and sometimes, a patient’s best interest is not to operate at all. Surgeons are not perfect, and our results will always be held up to self-criticism. Part of surgery involves an inevitable touch-up—an obligation we have within reason, of course.

In the past, we didn’t charge for touch-ups—until, that is, we realized the extent of just what an insatiable patient requires. Now, most of us charge, which discourages frivolous requests, but allows other patients touch-ups at minimal cost. This ensures satisfied patients. A steroid injection, a little more fat regrafting, or an external ultrasound to reduce postoperative edema are worth the effort to offer patients. Don’t be afraid to admit your results were sub-optimal; just be accommodating with touch-ups.

Never operate on anyone until you have spoken with him/her at length at least twice. Repeat procedure recommendations or rejections in front of witnesses before markings and medication. Another good idea for body sculpture or breast surgery is mark with washable ink on the first interview. Ask patients to look in the mirror at home before they wash off the markings, and write down their impressions. Keep photographs on permanent file, and give copies to each patient.

One joy of practicing plastic surgery is having a patient from 20 or 30 years ago call and urge you never to retire because, the patient says, “I won’t go to anyone else!”

Tolbert S. Wilkinson, MD, contributes extensively to textbooks, national magazines, and plastic surgery journals,  most notably Technical Forum. His surgical practice in San Antonio, Texas includes abdominoplasty, malar implants, extended surgery for aging skin, and breast surgery. He can be reached at: [email protected].