Cosmetic medicine is a whole category of life options in a world where options are more prolific than ever. Endless options create psychological stress for some people, with the ever present possibility of making the “wrong” choice. The results of major cosmetic procedures are usually permanent, and “type-changing” operations such as nose and chin recontouring, breast surgery, and lip enlargement alter one’s birthright by changing body characteristics destined by DNA. Psychological distress after cosmetic procedures, especially those that alter one’s long-standing facial identity, is not uncommon. Even good physical results may come with unanticipated effects on personal relationships. A patient may be successful in recharging her love life, or she may find that her partner is threatened by her new appearance and increased self-confidence. Similar effects have been reported in relationships in which the partners were previously fairly equal but are put off kilter when one person loses considerable weight or suddenly achieves professional success.
Much has been written about major psychological problems associated with cosmetic surgery, including body image disturbances and various forms of mental illness (cosmetic surgery addiction, eating disorders, delusional disorders, schizophrenia, and others). Studies indicate that up to 15 percent of people seeking cosmetic surgery have BDD, the most severe form of body image disturbance. In genWhat eral, prospective cosmetic medical patients with known psychological problems are at significant risk for psychiatric complications after treatment.
OUTCOMES
Goals Versus Outcomes
A patient who, going into a procedure, understands the possible outcomes is more likely to be satisfied than one who has unrealistic goals or is under the influence of false promises. Traditional operations such as facelifts and rhinoplasties have much cumulative surgeon experience and well-defined goals. Some less invasive procedures also have clear benefits for most patients. Much of the trumpeted technology of today, however, is not so clearly proven. Each patient has to decide: What are my goals? How much risk am I willing to take? How much money, time, and convenience am I willing to sacrifi ce on procedures, even those with low risks, which may yield “slight improvement” at best? Prospective cosmetic patients should remind themselves that most people would abandon a therapeutic medical treatment of a non–life-threatening condition, and maybe even dump their doctors, if they couldn’t expect better than slight improvement.
The purpose of a cosmetic intervention is to improve one’s body image by changing one’s appearance, yet good outcomes studies of the psychological benefits of cosmetic medical care have been few, especially those that look at patients long term or exclusively at patients who have undergone only minor procedures. Still, the studies that do exist suggest that after cosmetic surgery most patients are satisfied with the improvements in the appearance of the targeted body parts and would have the surgery again or recommend it to others. Interestingly, several recent studies have not been able to demonstrate improvements in patient self-esteem after cosmetic surgery, despite the long-held belief that low self-esteem is a legitimate justification for surgery.
Physical Results—Less May Be Better
Patients sometimes set goals and achieve physical results that perplex others. For example, some ignore the widely acknowledged principle that subtlety is important for an attractive result. We continue to see an array of really quite dreadful post–cosmetic treatment images coming out of Hollywood and elsewhere, and one can only assume that the patient got what she (or he) asked for. Nonetheless, most actors do not want to reveal their cosmetic interventions, and good surgeons who see large numbers of celebrity clients defi ne a good celebrity outcome as an unremarked one. In the opinion of one West Coast surgeon most actors, in contrast to East Coast consumers, actually prefer the stepwise, discreet approach to cosmetic procedures. “The funny thing is that everyone thinks Hollywood is ‘done’—Hollywood is undone. New York socialites look much more ‘done’ than Hollywood people because Hollywood people don’t want everyone talking about them.”
Major physical alterations can actually be troublesome for celebrities, models, and other prominent people, whose appearance so often defines their careers or status. Paradoxically, they may lose their appeal, especially if they have been made to look too “mainstream.” The actress Jennifer Grey famously couldn’t get work after her rhinoplasty. A celebrity may experience even stronger reactions from fans. The English actress Leslie Ash received so much hate mail after she underwent disfiguring collagen injections to her lips that she feared for her safety. Others celebrities (and this undoubtedly happens a lot) feel compelled to lie to the press about their wildly successful diet and exercise programs while concealing the fact of their liposuction. Some apparently convince themselves that they aren’t really lying, á la Bill Clinton. The Palm Springs reporters who interviewed a local socialite were told that people in that community don’t lie about having had cosmetic procedures, they just lose track: “When someone says ‘I haven’t had any work,’ maybe she means she hasn’t had any today.”
A common feature of many cosmetic procedures, even some surgeries, is that the results are temporary. Sometimes the duration of the desired effect is operator dependent; other times it is inherent in the treatment itself. Thus patients never have a final or even semipermanent outcome; they must choose whether to stay on or get off the merry-go-round of treatments and, in the case of fillers, the seesaw of overfilled, looks good, underfi lled, overfilled, looks good, underfilled (or the reverse sequence).
Even the results of major surgeries such as facelifts and eyelid lifts can be considered impermanent in that aging and exposure continue to affect skin quality. Still, the benefits of these invasive procedures persist for years, and the patient will never return exactly to his or her preoperative appearance.
Some things cannot be undone, however. Implants can be removed, but tissue that has been discarded cannot easily be replaced. For example, it is very diffi cult to rebuild a nose after reduction rhinoplasty; it is challenging to lower eyebrows that are too high, and it is generally impossible to restore hair growth to large hairless areas (for example, on a man’s face after laser hair removal). The majority of patients who undergo cosmetic procedures have satisfactory physical results and good outcomes. Unfortunately, some patients have terrible outcomes, yet no one knows the size of this group because many bad results go unreported. However, there have been increasing numbers of anecdotal reports of poor outcomes from surgeons seeing these unfortunate patients in second opinion consultations. Finally, there is always a group of patients who have acceptable outcomes in the eyes of their surgeons but who are dissatisfied with their results for a variety of reasons.
PATIENT SATISFACTION
The satisfied patient, of course, is the true holy grail of cosmetic medicine. Still, although the underlying goal of a cosmetic intervention is to bring happiness by altering the body, good doctors won’t promise happiness and patients with good results are not always satisfied. This dissatisfaction occurs despite the efforts most doctors make to “weed out” poor candidates. A study published in 2005 looked at patients from the practices of highly respected, boardcertified plastic surgeons. After one year only 64 percent were extremely satisfied with their outcomes, and at least 13 percent were not satisfi ed.5 Considering that a cosmetic intervention is entirely optional and is for the sole purpose of improving one’s appearance, a 13 percent dissatisfaction rate even in the best of hands is not to be taken lightly. One can easily imagine that dissatisfaction among patients undergoing surgery by practitioners who are less well trained and less experienced is probably much greater, and the disappointment quotient for patients undergoing all those low-risk but largely ineffec tive cosmetic medical treatments is undoubtedly quite signifi – cant. In fact, the level of satisfaction felt by the substantial numbers of patients that compose these latter groups is unmeasured, unreported, and unknown.
Discussing facelifts and eyelid surgery in The Patient and the Plastic Surgeon, Dr. Goldwyn wrote, “During the first visit I try to weed out the patients who cannot stand imperfection because, frankly, most patients . . . will have imperfections; the fl awless result is seen more often in slides at meetings and in articles in journals [not to mention in promotional materials for cosmetic surgeons and in the popular press—author] than in one’s own office.” Dr. Goldwyn’s comments could easily apply to most if not all cosmetic procedures and patients.
Although the physician and the patient may disagree about a result, the patient’s satisfaction is paramount. Most physicians subscribe to the philosophy, “If you are happy, I am happy.” Some patients are ultimately satisfied but have considerable diffi culty with the recuperation, despite the absence of complications. A patient is almost guaranteed to have a rough recovery if he or she
• Is intolerant of disorder, unpredictability, or disruptions of personal
routines;
• Has difficulty complying with rules;
• Cannot handle disapproval by family members and friends.
No one wants to go through a cosmetic procedure of any kind and
be dissatisfied with the outcome. Good advice for prospective patients
is simple:
• Have a clear idea of your goals.
• Find a reputable and qualified surgeon.
• If uncertain, choose less rather than more. It is always easier to
do more later than to re-create what has been removed.
• Understand that no physician can legitimately guarantee a result.
• Know that complications can occur.
• Do not undergo major surgery in the hope of radically altering
your life.
• Accept that after a surgical procedure you will have visible
scars.
• Understand that you may need further treatment in order to
improve your result.
• Accept that your final result will not be perfect.
The Dissatisfied Patient
Dissatisfaction after a cosmetic procedure can be related to poor physical results or to unanticipated psychological effects. Some patients hope for dramatic changes in their lives that do not materialize. Some expect to be awash in the attentions of fl attering admirers, and when this does not occur, they sink into depression. Others get attention that is unexpectedly negative. A person undergoing signifi – cant alteration of facial features, even major dental work, may look different in a way that can be disconcerting and even threatening to family and friends. Family tensions can develop when shared physical characteristics are altered by one member, and the patient may feel guilty or may even come to regret having undergone the change.
Patients themselves may be unable to adjust to major physical changes. In general, middle- aged and older adults have a harder time adapting to changes in identifying body contours—such as nose shape—and do better adapting to surgery designed to restore previous, more youthful adult contours (for example, facelifts and eyelid lifts). This is not to imply that a patient choosing to have a nose job at the age of forty-five is necessarily going to be unhappy with the result. Still, a forty-five-year-old will probably have a harder time adjusting to a new nose than would a twenty-year-old. Certainly, a forty- five-year-old who has hated her nose since she was sixteen is more likely to be satisfied than is a forty- five- year- old who developed dissatisfaction with her nose when she was forty-two. The latter patient is much more likely to be projecting her unhappiness with some other aspect of her life onto her previously innocent nose. Patient dissatisfaction after a cosmetic procedure is often not related to the occurrence of a serious complication but is the result of poor communication between an uninformed or unrealistic patient and the provider. Surgeons and psychiatrists have also identifi ed a long list of red flags signaling a high-risk potential patient, such as one who
• Tries to bypass a doctor’s appointment system in order to get an
earlier consultation appointment and is annoyed when a procedure
cannot be scheduled immediately;
• Tries to get overly chummy with the doctor’s staff and the doctor
before meeting them;
• Is unable to identify the “problem” or what he or she wants
done;
• Gives the provider carte blanche;
• Is extremely bothered by a feature that no one else can detect,
even when attention is brought to it;
• Has developed a recent dislike of a lifelong physical feature;
• Has not had prior treatment yet blames others for his or her appearance;
• Has decided before the consultation exactly what procedures
to undergo and does not want to hear about any alternatives;
What They Don’t Always Tell You 223
• Is counting on the procedure to expand his or her social circle,
lead to a relationship or job, or salvage a relationship;
• Wants to have a cosmetic procedure to please someone else;
• Wants to look like a certain celebrity, or any other individual;
• Expects not only to look younger but to feel younger;
• Has already seen multiple cosmetic providers, has had multiple
procedures, and can no longer obtain an appointment or get
calls returned from those other providers;
• Has scheduled and canceled a cosmetic procedure two or more
times for reasons other than illness or a true emergency;
• Gives a false medical history or lies about other personal information;
• Is in the midst of a life crisis;
• Has an unevaluated or untreated mental illness or substance
abuse problem and fails to reveal this information to the provider;
• Insists that the provider restrict the preoperative evaluation in
a way that impairs the formulation of a proper treatment plan;
• Is a perfectionist;
• Has seen three or more cosmetic providers for the same
problem;
• Is a cosmetic surgery addict;
• Is young and has already had multiple cosmetic operations;
• Is unhappy with the results of a previous cosmetic procedure,
especially if the new physician thinks the result is good;
• Wants a guarantee of results;
• Wants to have a procedure that another provider has deemed
unwise or unsafe;
224 t h e m a k e o v e r m y t h
• Tries to talk the provider into doing a procedure that the provider
does not enjoy doing or does not want to do on that patient;
• Dislikes, or is disliked by, the provider;
• Expects to be treated like a celebrity or “VIP”;
• Is not a celebrity but wants to have a highly covert procedure;
• Expects a great result because the provider’s fees are the highest
in town;
• Wants to undergo a cosmetic procedure despite strong disapproval
from significant others such as a spouse, immediate family,
and close friends;
• Lives out of town, wishes to undergo a major procedure, and
does not have a plan for follow- up;
• Is talked into undergoing a substantial appearance- altering
procedure that was not part of his or her original reason for
seeking consultation;
• Thinks that his or her current provider is the greatest and that
all the other providers in town are horrible.
Tags: disruptions of personal routines, dissatisfaction rate, Dissatisfied Patient, facelifts and eyelid surgery, PATIENT SATISFACTION, qualified surgeon