In surgery, there are no shortcuts. There are certainly more efficient ways to operate, which equal the proper ways to do surgery.

Nevertheless, one cannot eliminate necessary steps in order to save time or supplies.

Last month, I discussed physician-patient communication prior to surgery. This month, I wrap up this two-part article by focusing on the surgery and beyond.

Intraoperative assessments are critical. One should not simply decide what procedure is going to be carried out and go on autopilot.

For example, if your patient is at high anesthetic risk, do not operate. Otherwise, do not overschedule the number of procedures on individual patients or the number of patients or procedures per day, and do not rush through them.

As the saying goes, patients do not care how much you know until they know how much you care. My philosophy is to show them and prove it every time.

Most busy practices share the experience of receiving referrals from surprising sources. Thus, for both ethical and practical reasons, one should not prejudge which patients are worthy of more vigor and more time.

Rather, one should seek to meet and exceed expectations in both results, as well as exceed quality-of-care standards with every patient.


Recently, I reviewed a case that involved many of these principles.

After having three children, the patient wanted fullness and firmness returned to her breasts. She had a breast augmentation years earlier and consulted her plastic surgeon.

He saw her briefly and arranged to perform a procedure to replace her implants. At that point, he told her the procedure would be a “piece of cake.”

After the surgeon placed larger implants under the extremely thin, lax skin envelope, the patient was moved to an upright position and displayed a low, long, large-breasted appearance.

Despite the several operative cases and office visits that followed, an extensive capsulorrhaphy was then undertaken.

Detailed evaluation and planning could have prevented this operating room “surprise.”

The resulting discomfort and extended recovery time were quite a shock to the patient.

Particularly disconcerting were the serial office visits and intercostal blocks (with accompanying risk of pneumothorax) required for an apparent nerve entrapment.

This is always a risk of capsulorrhaphy, but certainly meticulous surgery can diminish it.

Planning and early communication of surgery risks will minimize the effects of unforeseen results.

Both the surgeon and the patient were frustrated. This led to poor body language, even less communication, and avoidance, which led to poor follow-through.

Feel free to ask your malpractice carrier in case you are not sure how this story ends.


When I was just emerging from plastic surgery training, I spent time shadowing a friend with a thriving, very high-profile practice.

One afternoon, we spoke with a woman who desired a tightening of her jowls. She had a full face and was a bit drawn from her two previous facelift surgeries. Her tragus was gone and was replaced by a coarse, albeit lightly colored scar.

As my friend deferred and referred her to other resources, I naively implored, “But she is going to get it done.”

See also “Buyer Still Beware” by Lesley Ranft in the April 2007 issue of PSP.

“Yes” he pointed out, “but it is not going to help me—or you—in the long run. Certainly not the image of who you are and the perception of what you can do.”

In evaluating any case, I visualize the likely result and ask myself, if that is the best I can get, should I really do it? Would I stand by it like an artist in a gallery of his work?

I do not suggest that we operate only on obvious “home runs” and beauty queens. However, there should be a palpable, clearly anticipated benefit that a reasonable patient will value and appreciate.

Scott R. Miller, MD, is an attending surgeon at Scripps Memorial Hospital in La Jolla, Calif, and a voluntary clinical instructor of plastic surgery at the University of California, San Diego. [email protected].