shutterstock_19947364It’s an all-too-common scenario: A patient who is convinced that a breast augmentation will save her rocky relationship or one who is now on rhinoplasty number 7 because she still sees a bump, or maybe it’s a size zero female who is desperately seeking liposuction.

Sometimes a cosmetic surgeon just has to say, “No, I don’t think you are an appropriate candidate for this procedure.” Some may even have to gently suggest that the patient seek counseling instead of chiseling . This is harder still, because there is always another not-quite-so-reputable surgeon who will say, “Step right up.”

We spoke to several top surgeons to find out how they gently, but assertively, say no when it is in the patient’s best interest.

Here’s what they had to say:

“Saying ‘no’ to a patient with unrealistic expectations in one of the most difficult situations encountered in an aesthetic practice. Typically, providing education and having a thorough discussion of anticipated (but not guaranteed) results and downtimes are enough to manage and change most patients’ ‘preconceived’ unrealistic expectations. If, however, the patient continues to foresee certain outcomes that simply are not possible, it is best to be completely honest and not perform the treatment or procedure. Although the conversation may be awkward, frustrating, and disappointing for both parties, it is certainly better than any conversation that could take place after the procedure is performed.

“In terms of ‘how’ to present the ‘No,’ I simply state to the patient in an empathetic conversation and tone that the procedure won’t meet their expectations, and will lead to frustration for both of us because they would have spent money, time healing, and time off from work without achieving their goal. Rarely, a patient may need a referral to a psychiatrist to be evaluated for body dysmorphic disorder (BDD) if they fall within the category.”

Tim MillerTimothy R. Miller, MD

Facial plastic surgeon

Refreshed Aesthetic Surgery

Aliso Viejo, Calif


“I probably turn away 10% or more of patients who come in seeking cosmetic surgery. Some are looking for something unrealistic; others are unrealistic candidates from a health perspective. I explain why they are not a good candidates or why it’s not a wise thing to do, especially if there is a risk in terms of their overall health. In other situations, I will guide them to a different procedure or defer the procedure until they lose weight—for example, when they no longer need the surgery, or it will be safer.”

Alan Gold 1Alan Gold, MD

Plastic surgeon

Great Neck, NY, and Boca Raton, Fla

Past president, American Society for Aesthetic Plastic Surgery, Aesthetic Surgery Education and Research Foundation, and American Association for Accreditation of Ambulatory Surgical Facilities

“When a patient comes to my office to discuss a procedure and they have unrealistic expectations, I explain to them why their goals are unattainable with the requested procedure, and I give them my reasoning why this is so. I also explain to them that if they keep seeking out doctors to perform their desired procedure, they may find one, but the end result will not be what they anticipated.”

roweNorman M. Rowe, MD, MHA, LLC

Aesthetic and Reconstructive
Plastic Surgery

New York City



“I like to put this back on the patient. I try to educate him/her on the importance of meeting expectations, and apologize, going on to explain that I simply do not want a disappointed patient, and given what I feel are the patient’s overly high expectations, she/he is a setup for disappointment.”

Epstein_Jeffrey_newJeffrey S. Epstein, MD, FACS

Facial plastic surgeon

Director of the Foundation for Hair Restoration

Miami and New York City


“One of the hardest things to do is to tell a patient no. Why is this so difficult? There are many answers to this question. From our first day of practice, we are keyed to market our brand to draw patients on which to perform our passion: cosmetic surgery. The patient is our life’s blood, as we are nothing without them. We invest maximum energy into not only attracting patients, but perfecting our art to ensure positive outcomes—which make happy patients, which brings in more patients.

“Having said this, when a patient presents for our care, it is an honor and a compliment so it is hard to turn them away. It flies against all our instincts and actions to draw patients, not repel them.

“It is extremely difficult for a young surgeon, new in practice, to say no. Here you have a patient sitting across from you with a problem and a checkbook. Why would you want to turn them down? Every seasoned cosmetic surgeon can answer that question.

“One percent of your patients can cause 99% of your problems. An unhappy postsurgical patient with BDD and/or other psychological problems can turn your professional and personal life upside-down. They can bug you, they can defame you, they can sue you, and they can stalk you, or worse.

“Surgeons have to almost experience a ‘bad’ patient several times to really understand how it can embezzle and sap positive energy out of the surgeon, spouse, and staff. Much has been written about ‘red flags,’ and it would behoove all novice surgeons to become familiar with the common ones.

“If you have a patient sitting across from you at consultation and ‘it does not seem right,’ the best way out is to listen to them, be courteous, and simply say, ‘I am honored that you consulted with me, but I don’t think I can achieve the results you desire or make you happy.’ Sometimes I thank the patient and tell them that I will review their case and get back with them. I will then contact them at a later date and tell them I have decided not to accept their case.

“Sometimes they get mad, but usually they understand as they probably have heard it before. Finally, listen to your staff. They frequently can see trouble on the horizon.”

joe niamtuJoe Niamtu III, DMD

Cosmetic facial surgeon

Midlothian, Va

Secretary, American Academy of Cosmetic Surgery